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Above the Fold

Health Care Law Supporters Ought to Be Sentenced to Serve as Governors

Apr 5, 2012• 10

By Sen. Lamar Alexander

During the debate two years ago over the health care law—which I called an historic mistake because it expanded a health care delivery system we already knew was too expensive, instead of taking steps to reduce its cost two years ago—I suggested to our colleagues on the other side of the aisle who were supporting it that, if they voted for it, they ought to be sentenced to go home and run for governor and see whether they could implement it over an eight-year period.

Governors have long wrestled with the rising costs of Medicaid, paid for partly by the states according to rules set in Washington, and the question of how to deal with public education, especially higher education. Some 30 years ago, when I was a young governor, I was still struggling with the fact that at the end of the budget process, we had money either to put into higher education or into Medicaid – but the rules from Washington said it had to go to Medicaid.

I remember going to see President Reagan and asking: ‘Why don’t we just swap it, Mr. President? Let the federal government take all of Medicaid. Let the states take elementary and secondary education.’ That didn’t happen, and gradually, the increasing Washington-directed costs have distorted state budgets so much that now 24 percent of the state budgets go to the Medicaid program.

Because of the health care law, we are going to add 25.9 million more Americans to Medicaid, according to the Medicaid Chief Actuary.

Our former governor, Governor Bredesen, a Democratic governor, estimated that between 2014 and 2019 the expansion of Medicaid would add $1.1 billion in new costs to the state of Tennessee.

Jack Cochran, The Permanente Federation

Apr 5, 2012• 2

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The Permanente Federation is the national organization for Kaiser Permanente’s doctors. In this interview taken at HIMSS12, Executive Director of the Federation Jack Cochran gives an overview of transitions physicians are undergoing in the workplace. He also debunks what he says is the biggest myth about patient to doctor emails.

The Magic of Doing One Thing at a Time

Apr 5, 2012• 2

By John Halamka, MD

I’ve previously written about multitasking and work induced attention deficit disorder.

I’ve also written about the burden of having two workdays every 24 hours – one for meetings and one for email

Yesterday, I was sent a post from the Harvard Business Review that summarizes these issues very well.

It highlights the problem and a series of solutions.

Nearly half of employees report the overwhelming stress and burden of their current jobs, not based on the hours they work, but the volume of multitasking – too many simultaneous inputs in too little time. They’ve lost the sense of a beginning, middle, and an end to their day, their tasks and their projects. There is no work/life boundary.

As a case in point, I’m writing now while doing email and listening to a Harvard School of Public Health eHealth symposium. Am I being more productive or just doing a greater quantity of work with less quality?

The author of the post points to evidence that multi-tasking increases the time to finish a task by 25%. He also notes that our energy reserves are depleted by a constant state of post traumatic stress induced by our continuous connectivity.

He suggests three strategies:

1. Rather than multi-task, reduce meeting times to 45 minutes, leaving 15 minutes for email catchup and transition.

Everyone Should Learn the Entrepreneurial Method

Apr 5, 2012• 4

By Saras Sarasvathy

When I was a teenager, the older women in my family taught me to cook. I learned it was traditional not to add salt when cooking lentils, because it would slow down the cooking. For some reason, perhaps the sheer pleasure of being difficult, I insisted on taking two identical pots and cooking identical quantities of lentils, one with salt and one without. That caused quite a bit of a stir, and not only because I proved that the salted lentils cooked just as fast. On the one hand, my mother, grandmother, and aunts sensed more difficulties were to come. On the other, they knew they’d participated in something different and important: a scientific experiment.

The women in my family were courageous, smart, and resourceful. They knew many things: useful wonderful things. For the most part, their knowledge was received knowledge, knowledge they’d been given, not figured out on their own. This is a common situation. The idea that anybody can be taught to figure things out, that there is a logic to discovery and invention, would have struck our ancestors as radical and strange. Until quite recently — until science education became institutionalized and widespread — the creation of new knowledge depended on either genius or luck.

Pay for the “A”

Apr 4, 2012• 5

By DINOSAUR MD

Medicine is simple and straightforward; except when it’s complex and nuanced.

Medical diagnosis is a simple matter of taking a history, performing an examination, and reviewing the results of ancillary testing; except when it’s a complicated case of eliciting subtle nuances from the patient in both the interview and the exam, and interpreting multiple pieces of conflicting data.

Medical treatment is a straightforward affair of providing appropriate treatment; except when there are multiple treatment options with unclear risks and benefits, technically challenging surgical or other procedures to perform, not to mention fully informing the patient and family about all of those treatment options, risks, and benefits, plus eliciting and answering all their questions.

Nothing to it.

Notice, though, that the key ingredient here is DIAGNOSIS. Performing a flawless appendectomy won’t do a thing for an ovarian cyst, nor will a PPI prescription do much for an acute coronary syndrome. Performance measures that look at treatment without addressing diagnosis are somewhere between misguided and ludicrous.

Why does American medicine have this so bass-ackwards? Follow the money. Thanks to the specialty-heavy RUC, the commission that sets fees for various procedures, doing something — anything — is paid far more handsomely than thinking (even thinking about what to do).

Romney’s Second Shot at Healthcare Reform

Apr 3, 2012• 2

By Jim Stergios and Joshua Archambault

Americans believe in second chances. The oral arguments before the Supreme Court last week were a rare opportunity to dispassionately re-examine the divisive healthcare debate of two years ago. What happens if, after the smoke clears, we get a second chance at healthcare reform?

We’ve long known that healthcare will be a central theme in the 2012 presidential contest. The High Court’s deliberations and June decision only reinforce that reality for President Obama and Governor Romney.

Unlike with the Patient Protection and Affordable Care Act (PPACA), the constitutionality of Governor Romney’s Massachusetts law has never been seriously questioned. States, not the federal government, have police powers, allowing them to require purchases (car insurance, taxes and licensure) and to pass wide-ranging public health laws and public safety laws. The Bay State law enjoys broad popular support.

In contrast, the case before the Supreme Court was brought by the majority of states. Regardless of what the Court decides, the PPACA will continue to polarize the country.

President Obama may cite Romney’s Massachusetts reform as inspiring his efforts, but there are profound differences in the size, reach and financing of the two laws. Elected just six months after the law’s passage, Romney’s successor, Democratic Governor Deval Patrick, has obscured some of those differences by taking a big government approach to implementation.

Where Romney sought an open marketplace for individuals to purchase benefit plans ranging from catastrophic to generous, Patrick has drastically limited choices and mandated minimum coverage levels beyond private-market norms.

The Supreme Court on Moral Hazard

Apr 3, 2012• 49

By David Dranove

I have had to take some time off for the funeral of someone very near to me, so I have not had a chance to comment on the Supreme Court hearings. Nor do I have much time to do so now. But I would like to comment on Justice Alito’s line of questioning about burial insurance. His questioning was in response to one argument used to justify the purchase mandate, namely that sick individuals will receive medical care at someone else’s expense and therefore there is an economic justification for mandating the purchase of health insurance in order to prevent free riding. Alito noted that individuals who did not provide for their own burials will still be buried at taxpayer expense. This is another form of free riding. If the Supreme Court were to uphold mandatory purchase of health insurance, could Congress not also mandate purchase of burial insurance?

Solicitor General Donald Verrilli seemed surprised by Alito’s questions and did not provide a good answer. Yet these questions strike at the heart of the case and at deeper economic issues. There is a direct analogy between the market for burials and the market for healthcare. Just as some patients free ride off of the generosity of others, some deceased do the same thing. By extension, any time that a good is provided at a price below cost, whether by the government, a charity, or any other organization for that matter, we can expect a certain degree of moral hazard behavior. Some individuals who ought to purchase the good themselves will instead free ride on the generosity of others.

Be Careful What You Wish For

Apr 3, 2012• 6

By MICHAEL TURPIN

As the Supreme Court considers the testimony presented at the recent hearings over the constitutionality of certain provisions of the Patient Protection and Accountable Care Act, the debate continues to escalate over the role that individuals, business and the government should play in the “commerce of health care.”

Most industry experts agree that PPACA is first about insurance reform and the expansion of coverage to some 30m Americans; yet, detractors have criticized the legislation for failing to incorporate any elements that would serve as a catalyst for reducing costs, improving quality and restructuring a misaligned system that has been paid to treat illness rather than prevent it.

In the last two years, hundreds of millions of private and public dollars have been invested as stakeholders adjust to an uncertain but radically changing delivery system. States are in various stages of constructing purchasing exchanges. Physicians and specialists are choosing to consolidate, often with hospitals leading the process to create integrated delivery systems and restore the role of coordinated care through Patient Centered Medical Homes and Accountable Care Organizations. Employers are waiting and watching — seeking greater regulatory clarity while slowly complying with a chronological time-line of new rules and expanded coverage requirements.

Municipal, state and national budget deficits continue to loom large. As Europe battles over mounting sovereign debt and the suffocating burden of generous public pension and healthcare entitlements, flash points are erupting across the USA as municipal, government and collectively bargained workers brace to defend retiree benefits in the face of legislative efforts to more aggressively reduce public spending. The Federal government is at a tipping point. Facing a $38T net present deficit in its funding for Medicare and $15T of public debt, PPACA was scored by the CBO as reducing $140B of public debt by 2020. To achieve this, the government needed to drive $940B of taxes, assessments and spending cuts and fall within estimates of the number of newly insureds likely to qualify for Federal subsidies offered through public exchanges. The promise of PPACA was to reduce the deficit, not further contribute to it.Continue reading…

Health Care Reform: Good for Business

Apr 3, 2012• 6

By Brian England

Last week, the U.S. Supreme Court heard six hours of oral arguments for and against the constitutionality of the new health care law. As a small business owner, I am not a constitutional scholar, but I can definitively say this: the Affordable Care Act is cutting my health care costs and helping my business.

My wife and I run an auto repair shop in Columbia, MD. We started as a small, family-business in 1978. Now, we’re a well-respected business with 19 employees, a long string of awards and a reputation for service.

One of the biggest barriers to growing a successful business has been the rising cost of health insurance. We’re committed to offering insurance coverage, but over the past 10 years it has become a real struggle to keep up with the costs.

We’ve become accustomed to rates going up 10 percent to 20 percent each year (sometimes even more), and we’ve had to look at many different ways to deal with the extra expense. We’ve got a great agent who does a lot of research and works hard to find the best options for us. But in the end, we’re the ones who have to decide what to do — and foot the bill.

Is There a Republican Alternative to ObamaCare?

Apr 2, 2012• 10

By John Goodman

“GOP to the Uninsured: (Feel Free to) Drop Dead.” So reads the title Michael Millenson post at the Health Care Blog yesterday. It gets worse:

[N]o Republican presidential candidate has ever presented a serious plan to cover all the uninsured … The difference between Democrats and this generation of Republicans — unfortunately including even the GOP Doctors Caucus — is not at its core a disagreement on what government can legitimately do to help create universal access to health care for the 50 million Americans without it, but whether the goal itself is worth pursuing.

Was Millenson completely asleep (like Rip Van Winkle) during the last election? Does he not read my Wall Street Journal editorials? Does he never visit my blog? Or was this meant to be an April fool’s column?

John McCain’s health plan was more radical and even more progressive than Obama Care. I’ve never seen any serious health policy wonk deny that. Maybe Millenson doesn’t live in a battle ground state. If he did, he would know that the Obama campaign spent more money attacking the McCain health plan during the election than has ever been spent for or against a public policy idea in the history of the republic. In fact, it is probably no exaggeration to say that Obama successfully turned the election into a referendum on the McCain health plan!

The McCain health plan is discussed at this blog here, here, here, here and here.

And although Millenson singles out Oklahoma Senator Tom Coburn as an especially egregious example of the Republican failure on health policy, the McCain vision actually was based on a bill, sponsored by Sen. Coburn and Sen. Richard Burr (R-NC), along with Reps. Paul Ryan (R-WI) and Devin Nunes (R-CA), [hereinafter called the Coburn bill]. That bill, in turn, was based on an idea which Mark Pauly and I proposed in a Health Affairs article more than a decade ago. (Does Millenson not read Health Affairs?)