The Health Care Blog – Page 685 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Romney vs Romney

Oct 29, 2011• 9

By ROBERT LASZEWSKI

Republican presidential frontrunner Mitt Romney has pledged to end “Obamacare.” Upon taking office, he would immediately begin the process by granting the states waivers from having to implement it:

“I’ll grant a waiver on Day One to get repeal started. On Day One, granting a waiver for all 50 states doesn’t stop it in its tracks entirely. That’s why I also say we have to repeal Obamacare, and I will do that on Day Two, with a reconciliation bill [requiring only 51 votes in the Senate] because as you know, it was passed by reconciliation with 51 votes.”

Romney appears to be on thin ground in making his waiver promise and his promise to use reconciliation to stop “Obamacare” could lead to chaos in the market and among consumers.

The waiver promised is based on a provision in the law authored by Senator Ron Wyden (D-OR). Wyden’s provision was designed to allow states to petition the feds to opt out of the new health care law by taking the federal money that was going to be spent in their state under the Affordable Care Act and draft a comprehensive plan of their own that covered at least as many people as well as the Affordable Care Act would have.Continue reading…

How Much Is a Life Worth?

Oct 28, 2011• 105

By DAVID DRANOVE

This blog continues my ongoing series of “mysteries of health economics.”

The mystery this week is “what is a life worth?” We cannot ignore this question because it seems unthinkable. As will discuss, coverage decisions by public and private insurers depend on the answer. Some payers are rather explicit about they think a life is worth.

Before I try to solve this mystery, let me acknowledge that we should not spend money on health services that are of zero value (or worse.) But what about expensive health services that might prove to be of some value? How much should we spend on these?

Let us accept the reality of insurance. When we “purchase” health care, someone else foots the bill. Perhaps insurance should contain big deductibles, but even big deductibles are quickly exhausted if we need surgery or have a chronic health problem. If we are pooling our resources to pay for medical care, then we will probably want to reach some sort of collective decision about what drugs and treatments we will pay for. The alternatives would be to invite massive moral hazard. (Let me repeat for those who bang the drum loudly for big deductibles – deductibles are quickly exhausted when serious illness strikes and moral hazard again rears its ugly head.)

Now imagine a new cancer drug that offers a small prospect of survival to patients who have no other choices. Suppose that on average, patients who receive this drug can expect to live about another three months and that there are no downsides to this drug. If the drug company offered to give the drug away for free we would surely want patients to have access to it. If the drug company asked $100 million a dose, we would probably agree to spend the money elsewhere.

The Massachusetts Disconnect

Oct 28, 2011• 4

By Trudy Lieberman

Much of the national press took a pass last week on another important “study says” story out of Massachusetts. This is the second time in the last month where the national media missed a story with implications for the success of health reform. The latest report, which came from the Harvard School of Public Health and the Blue Cross Blue Shield of Massachusetts Foundation, showed that Massachusetts residents have different views about what’s causing the high prices of medical care than do the state and national policy wonks who are framing the solutions. What a surprise! We have repeatedly reported that the public is disconnected from what the pols are saying. Why should we be astonished they are not in step with the policy community?

The study, says lead researcher Dr. Robert Blendon, found that the public generally believes the cost problem stems from excessive charges by drug companies, insurers, and hospitals. Why not doctors? “Doctors have managed to present a picture in the state that they are not the reason why costs are rising. It speaks to the efficacy of the physicians’ campaign that their fees are not high enough,” Blendon told me. Indeed, doctors around the country have mounted local media campaigns to build their case that Medicare’s fee cuts will result in patients not getting care. Furthermore, the state media have focused mostly on the duel between hospitals and insurers, and that’s the message the public has received.

Health 2.0 Europe–the view from hip Berlin

Oct 28, 2011

By Matthew Holt

It’s morning on Day 2 of Health 2.0 Europe. We’re at the on the campus of Charité Hospital and University of Medecine (in the old East Berlin) in the Langenbeck-Virchow Building which is now a conference center for medical societies but apparently was used as a part of the old GDR parliament before 1989.

Yesterday, we had a series of intense panel discussions, not least between the German members of the panel who were discussing (and disagreeing) on whether Health 2.0 tools could come “bottom up” or would have to fit in the rather slow creation of national electronic infrastructure for clinical care.Continue reading…

Constitutional Serendipity

Oct 27, 2011

By David Boyle

Serendipity is not a word one usually associates with the present raucous debate over the “individual mandate” of the Patient Protection and Affordable Care Act. Democrats tend to support both the mandate and the PPACA, while Republicans tend to oppose both. However, this “between the devil and the deep blue sea” approach, whereby one makes a Hobson’s choice between being tyrannized by a government command to buy health insurance, or seeing no comprehensive health reform enacted in a country that needs it, is a false dichotomy, serendipitously enough.

The PPACA offers comprehensive reform, including welcoming features such as guaranteed issue of insurance regardless of preexisting medical conditions. However, the fact that the PPACA has valuable features doesn’t automatically legalize any possible measure designed to fund the Act, including coerced health insurance purchase. As former Vermont governor Howard Dean noted in August 2010 on MSNBC’s The Daily Rundown, Vermont enacted a successful state health care program without an individual mandate; Dean emphasized, “And people don’t like to be told what to do.” This latter factor is not negligible in a country with a statue in New York Harbor dedicated to liberty. (Perhaps this is why a June 9, 2011 CNN poll shows 54% of Americans opposed to the mandate, and other polls report similarly.)

Our American liberty has various constitutional and legal underpinnings which can defend people from the federal individual mandate, and maybe even from state individual mandates. As for Congress’ power to tax for the general welfare: taxes and penalties, such as the “Shared Responsibility Payment”, the PPACA financial penalty for refusal to buy health insurance, are not just interchangeable “economic incentives”.

No Better Care, Thanks to Tort Reform

Oct 26, 2011• 25

By Charles M. Silver

In 2006, Dr. Howard Marcus wrote that Texas’ 2003 tort reform statute sparked an “amazing turnaround” in which doctors came to Texas in droves, instead of leaving the state as they had before. He was doubly wrong. Texas neither lost doctors before 2003 nor gained them especially quickly in subsequent years. In fact, according to statistics published by the Texas Department of State Health Services (TDSHS), the supply of active, direct patient care (DPC) doctors per capita grew faster from 1996 to 2002 than at any time after 2003. If the pre-reform growth rate had simply continued, Texas would have seven more DPC doctors per 100,000 residents than it does today.

Not only did pre-reform Texas outpace post-reform Texas; in the post-reform period Texas fell farther behind the average U.S. state. In 2002, Texas had 61 fewer DPC physicians per 100,000 residents than the average state. In 2010, Texas lagged the average state by a whopping 76.5 doctors per 100,000 residents, according to data published by the American Medical Association (AMA). Texas’ downward slide is also accelerating, meaning that Texas is falling behind the average state both farther and faster each year.

These statistics are public and well known. They can be found at TDSHS’s website and in a report Public Citizen published earlier this year. In view of this, it is shameful that Marcus, his colleagues at the Texas Alliance for Patient Access and Republican politicians continue to mislead. They are blatantly exploiting the ignorance of people who have better things to do than read up on the number of doctors in the State.

Marcus and his accomplices know about TDSHS’s numbers but have ignored them in all prior public statements I’ve found. They want to give glowing reports, so they focus on the number of new licenses granted by the Texas Medical Board (TMB) instead. TMB’s count of new licenses is misleading, however, because it ignores the number of doctors who leave the state, retire, die or stop seeing patients for other reasons. Suppose 100 calves were born into a herd of cattle that also lost 250 adult animals because of the heat and drought. The rancher who owned the herd would say he was down 150 head. Marcus and his buddies would say the herd grew by 100.

Better Care in Texas Thanks to Tort Reform

Oct 26, 2011• 21

By Howard Marcus, MD

Thanks to the passage of lawsuit reforms, medical care is now more readily available in many Texas communities. For many patients, this change has been life-altering; for some, life-saving.

George Rodriguez walks today thanks to tort reform. Newly established Corpus Christi neurosurgeon Matthew Alexander urgently operated on Rodriguez’ spinal abscess, relieving the pressure on his spinal cord, and sparing him life in a wheel chair. Without the state’s lawsuit reforms, Dr. Alexander wouldn’t have relocated to Texas and Mr. Rodriguez would have been deprived access to emergency neurosurgery in Corpus Christi.

Cancer survivor Ruby Collins credits newly minted Brownwood urologist Daniel Alstatt with saving her life. Dr. Alstatt says he wouldn’t have moved there, were it not for tort reform.

Andrya Burciaga of McAllen, a complex patient with diabetes and hypertension, is a first-time mother, thanks in part to the expertise of obstetrician/fertility specialist Dr. Javier Cardenas. Again, if not for the passage of the reforms, Dr. Cardenas says he absolutely would not have returned to his hometown to practice medicine nor taken problem pregnancies such as Ms. Burciaga’s.

Because of reforms, more patients across Texas are getting the care they need, when they need it.

Eight years ago, Texas was in the throes of an epidemic of lawsuit abuse. High numbers of meritless lawsuits, combined with excessive awards, caused doctors’ medical liability rates to double within just four years. Non-profit nursing homes saw their rates jump 900% within that same time frame, while hospitals saw liability costs increase as much as 50% in one year. Roughly one in four doctors was sued every year while the vast majority of these suits and claims were closed without payment.

A Vision for Health Care: Put the States in Charge

Oct 25, 2011• 7

By Victor M Sandler, MD

In an ideal world, all our doctors would have the wisdom of Marcus Welby, and all our nurses the compassion of Florence Nightingale. This medical world would be populated with doctors who all graduated No. 1 in their classes, who perform only necessary surgery — and without complications. These doctors would always wash their hands between patients to minimize the spread of infection. All medical research would be funded by nonprofit foundations to preclude bias. And, of course, all doctors would be salaried to avoid perverse incentives to do too much to too many.

Recently, the United States Preventive Services Task Force recommended against prostate-cancer screening, saying it doesn’t save lives overall and often leads to additional tests or treatments that do harm. Two years ago, the same task force, which is made up of nonfederal experts in primary care, recommended against screening mammography for women in their 40s.

What would Dr. Welby and Nurse Nightingale have said about the task force recommendations? I believe they would have endorsed them, because they are carefully researched and objective.

Yet both recommendations have been met with widespread protest. The task force has been accused of rationing — the dirtiest word in American medicine.

Why? Because a chasm separates the idealized world of American medical practice and our current reality.

Obamacare Exchange Opposite of Free Market

Oct 25, 2011• 3

By Jack McHugh

As described here last week, the latest tack of Republican Obamacare “exchange” proponents is to characterize their “MIHealth Marketplace” as a positive good rather than a least-bad option among several bad choices.

They are even using labels like “conservative” and “free-market” to describe the entity whose main role will be to administer the billions of dollars of insurance subsidies the federal Patient Protection Act distributes.

The boosters are also trotting out the old canard that the exchange is merely a “Travelocity and Orbitz” for health insurance.

Those claims and labels were badly dented in a recent hearing of the House Health Policy Committee, where staffers from one of the corporations hoping to profit from exchange contracts presented a “Mandated State Exchange Functions” flow-chart.

If a health insurance “Travelocity and Orbitz” is all these politicians really want, they’re in luck, because such websites already exist. Better yet, they really are “free-market” services provided by private companies, with no role in administering Obamacare — go to www.ehealthinsurance.com or www.getinsured.com to see examples.

CMS’ Opportunity: A Lawsuit Offers A Chance To Reform Physician Payment

Oct 25, 2011• 1

By BRIAN KLEPPER & DAVID KIBBE, MD

By mid-November, the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) must respond to the legal complaint filed in a Maryland federal court by six Augusta, Georgia family physicians.

These doctors are not asking for money, but for relief from the negative effects brought about by CMS’ twenty year reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC) for valuing doctors’ work. They are asking CMS to enforce the Federal Advisory Committee Act(FACA), which requires that regulatory agencies shield themselves from undue special interest influence. In the process, they are asking CMS to rethink Medicare’s approach to physician payment, with a mind toward recognizing and valuing primary care’s ability to treat the whole patient within a larger system of care. They are asking CMS to develop payment policy that supports the needs of patients over those of professional groups.

In a sense, the suit reflects the larger concerns of America’s increasing unrest: a general frustration with a system rigged to benefit the few at the expense of the many, privatizing profits while socializing losses. It calls into question an incentive structure that has resulted in half or more of all health spending providing no utility and translating to exorbitant cost but debatable value. In other words, the case is accompanied by a sense that the system, as it is currently constituted, is failing the American people.

Any simple examination of medical services payment reveals the systematic under-valuing of primary care services relative to procedural services, the direct result of the RUC’s valuation process. For example, in an earlier Health Affairs Blog post we compared a 99214 moderately complex established office visit with a routine cataract extraction and intraocular lens implant. The first has all of medicine as it’s palette. The second is a highly refined, low risk, repetitive procedure that is valued, on an hourly basis, at 12.5 times the first.