The Health Care Blog – Page 853 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Time to put aside the intellectual disputes for now

Oct 31, 2009• 75

By Matthew Holt

It’s always fun to see my friends beating each other up in public….and if you read down in the comments on the post published yesterday you’ll see a significant dispute between Maggie Mahar and the Klepper/Kibbe/Lazsweski/Enthoven team (who I’m calling the Four Horsemen from now on). But I think that right now we need to change what we’re talking about.

I’m with Maggie in that there is potentially more in terms of changing the payment system in the current bills than nothing, but it’s not that much more than nothing. However, pressure from the the Four Horsemen and their fellow travelers on payment reform may increase that section of the bill as it gets worked out on the floor and in the Congress conference committee. Their pressure will also serve notice that aware, sensible people are looking at the issues of payment and delivery reform.

And at the least, the proposals in the bill don’t make the current delivery system any worse (other than the exemption from taxes for self-insured groups which clearly discriminates against integrated systems and must go).

Why McAllen Should Have Mattered in the Health Reform Debate

Oct 29, 2009• 45

Jeff Goldsmith Back in June, Atul Gawande, a Harvard trained surgeon, published a riveting article in the New Yorker about the physician community in McAllen Texas. If ever an article was strategically timed to influence the nation’s health policy debate, this was the one. His story was accompanied by a graphic showing a patient as an ATM machine. President Obama read it and put it on his staff’s reading list. Yet, it’s depressing how little impact Atul’s article has had on health reform.

Atul’s purpose was to explain a major policy conundrum: why some communities manage to spend as much as triple on Medicare services as other communities. McAllen’s physicians practice some of the most expensive medicine in the United States, second only to Miami, and spend seven thousand dollars per Medicare beneficiary more than the national average. Peter Orszag has said that eliminating this type of variation could cut Medicare expenses nationally by as much as 30% and actually improve the quality of care.

A Bill of Rights for Health Care Reform

Oct 29, 2009• 12

Our nation’s Founders created a pretty good system of government by starting from what they wanted to achieve, exemplified by the Bill of Rights, so perhaps we would be wise to base health care reform on a similar footing. Instead, Congress is doing its usual muddled process to produce legislation that is likely to make no one very happy, but at least tries to minimize the number of people made very unhappy. As is too often the case, it is easier to create straw men to attack than to address the real problems. Insurance companies seem to be everyone’s favorite target to demonize, but the “evil” health insurance industry is like the various other players in the health care system: responding to the numerous and often perverse incentives in the current system. There are bad things done to people by insurance companies — as there are done by doctors, hospitals, government, and just about every other player in the health care system. There are both angels and demons working in health care, but mostly it is just normal people. Perhaps ninety-nine percent of the people working in the health care system try to do right by the people they serve, but “doing right” may not mean the same thing to different people.

A Message to America’s Physicians: Purchasing EHR Technology A Shaky State of Affairs

Oct 28, 2009• 31

By Brian Klepper and David Kibbe

Much of the conversation and debate about physician EHR adoption has centered on the single issue of the (high) cost of purchase. However, we’d like to suggest that the situation is much more complex and involves several more subtle variables.

Consider, for example, uncertainty about the future. In a recent speech, Lawrence Summers, Director of the White House’s National Economic Council for President Barack Obama, related the following analysis about decision-making under conditions of uncertainty in the marketplace, which he had first heard from Ben Bernanke, current Chairman of the Federal Reserve, in a speech Mr. Bernanke gave over 30 years ago:

“If you as a business were considering buying a new boiler, and if you knew the price of energy was going to be high, you would buy one kind of boiler. If you knew the price of energy was going to be low, you’d buy another kind of boiler. If you didn’t know what the price of energy was going to be, but you thought you would know a year from now, you wouldn’t buy any boiler at all. And in exactly that way, it is illustrated that the reduction of uncertainty, through the resolution of disputes, is, I would suggest, all important, if we are to maintain confidence.”Continue reading…

Senate Health Care Reform: Two Huge Problems, One Giant Red Herring

Oct 28, 2009• 13

By ROGER COLLIER

Pity poor Senator Harry Reid. Not only is he facing an uphill reelection fight in Nevada, but as Majority Leader, he must reconcile the health care reform bills from the Finance and the Health, Education, Labor and Pensions committees so as to attract sixty Senate votes. He’s guaranteed support from the more partisan Democrats, but to attract Democratic and one or two Republican centrists without losing liberals, he has to find ways to deal with two huge problems with the bills—and one giant red herring.

The giant red herring is the public option, THE big stumbling block for reform, mostly thanks to the efforts of lazy-thinking doctrinaire politicians of both parties—especially in the House. (Yes, Speaker Pelosi and Minority Leader Boehner, I mean you.) The reality is that for a public option to provide an adequate network, its payments to hospitals and physicians must be at least at Medicare levels. As experience with Medicare Advantage shows, this means its costs will be close to those of private coverage or higher, especially if it adopts Medicare’s uncontrolled fee-for-service structure and attracts the least utilization-conscious providers and patients. All this makes nonsense of liberal claims that the public option is necessary to control costs, and equally, of conservative allegations that it will destroy the insurance industry—and leaves Senator Reid’s “opt-out” solution looking merely perverse.

Commentology

Oct 28, 2009• 2

Jeff Goldsmith writes:

As you may know if you’ve read my postings, I’m an outspoken advocate of tightening Medicare fraud and abuse laws. There will be a post on this in a day or two. It’s actually the stuff that’s legal that is the problem: doctors self-referring patients for radiological scans, surgery, hospitals admissions to facilities they have an ownership interest in. I think there is just as much “fraud” of this type- rampant self dealing- on the private insurance side.

The scandal is: what’s legal. And I stand by my earlier statement that the big money is in running up the tab on the privately insured, not in Medicare. On private insurers’ margins, I’ve never subscribed to the populist garbage about obscene profits. Uwe Reinhardt had an excellent analysis of the Wellpoint 10K the other day in the New York Times. Health insurance is actually not a very good business. Many of these firms would be a lot more profitable if they were better managed, and eliminated a lot of the paper and clerical overburden, and if they were more aggressive in bargaining with providers. Since the same companies process Medicare claims, I don’t see us escaping them. Management in both our private and public systems is mediocre and not improving. (Medicare has been without an Administrator for two years, spanning two administrations).

It’s really a waste of my time to participate in a philosophical BS argument about government=bad, private sector= good. That sort of ended after college for me. We have a mixed system. I’ve worked in both private and public sectors. If we want to cover the 55 plus population, my best case scenario is for Medicare to assume the insurance risk, and contract with well managed HMO type health plans to actually co-ordinate the care. We’ve both spend decades working in this field, Nate- 34 years in my case; I’ve spent most of my time in provider space, and have a much clearer idea than you do about where the waste is. Don’t get me started- if all you’re looking at is claims data, and in essentially one market, believe me, my friend, you don’t know what you don’t know . . .”

Glen Tullman on EMRs, life, the universe and everything

Oct 27, 2009• 1

By Matthew Holt

A couple of weeks back Allscripts’ CEO Glen Tullman was on the Cats & Dogs panel at Health 2.0 and he said some pretty controversial things about the state of EMR adoption (yes it was happening), certification of meaningful use (it was being diluted and the tax payer faced being ripped off) and other vendors, or at least one other vendor from small town Wisconsin that wasn’t playing fair in the quest for interoperability).

Given that I always enjoy talking to Glen and also that he’s as responsible as anyone else for getting Obama interested in the concept of why EMRs and automating health care matters (and therefore why there was so much money in both Obama’s campaign pledges and in the stimulus package for EMRs), I thought it would be fun to have Glen back on THCB to expand a little on what he told us at Health 2.0. And yes there was plenty more interesting stuff where that came from. (Be warned, the sound quality is not great, but its completely understandable)

Here’s the interview

The Business of Prostate Cancer: Putting Profit before Patients

Oct 27, 2009• 15

By Anthony H. Horan, MD

The Big Scare

During my 30+ years as a board-certified urologist I’ve seen quite a bit of suffering, much of it needless, in my opinion. In my work both in private practice and with the VA in Fresno, CA. I’ve encountered many men who’ve received treatment for prostate cancer that greatly diminished their quality of life and produced horrible side effects, but did absolutely nothing to prolong their lives. These patients served as the inspiration for The Big Scare: The Business of Prostate Cancer, a book I wrote, hoping to spare men from the over-diagnoses and over-treatment for prostate cancer that’s taking place in this country every single day. I contend that screening for prostate cancer with a blood test and treating the cancer, discovered in the absence of a palpable nodule, offer no measurable good that outweighs the measurable harm. Instead, I advocate interceding before a man is falsely diagnosed with clinically significant prostate cancer.

Prostate Cancer is relatively common disease, with about 260,000 men over the age of 50 diagnosed each year. But as daunting as that number may sound, the fact is that prostate cancer is a very slow moving disease with estimates showing that 94% of the cancers detected with the routine PSA blood test would not even cause death before the age of 85. More men die in accidents than of prostate cancer. The PSA is a test I have major qualms about and objections to. The PSA test has triggered an enormous number of expensive and unnecessary prostate biopsies, which have led to treatments, a rash of radiation and radical surgery injuries, and death. After undergoing radiation, only 55% of men retain erectile function. So this is an issue that not only impacts the lives of many men, but the lives of their significant others as well.

Most of the men over 40 who are reading this blog have heard about or even had a PSA test performed. But that does not mean that it’s a reliable indicator of prostate cancer – because it is not. The PSA test should not be given without first having a long conversation with your doctor – or not given at all. Starting in 1986, just after the PSA test was introduced, many doctors, other than urologists, started buying machines in order to make a profit by doing the tests in their offices. Following this, diagnoses of prostate cancer and its treatment rate started to soar. The biopsy rate quintupled and the number of men labeled prostate cancer victims doubled between 1989 and 1992. Despite this, statistics prove that no more cancers have been discovered since the introduction of the PSA than would have been found in a random series of men the same age – whose PSA is unknown.

You can tell your doctor that you don’t want the PSA test. That’s your right. The only men who should be having the test are those who’ve already been biopsied and diagnosed for prostate cancer. That said, the PSA test is indeed useful for another far more frequent prostate problem, found in ten-times as many men as aggressive prostate cancer. Benign Prostatic Hypertrophy – better known as BPH, is a prostate condition that can create real devastation for men in their later years.

When I went to medical school at The Columbia University College of Physicians and Surgeons and also during my urology residency at the Columbia Presbyterian Hospital in New York in 1973, non-intervention was the rule. We didn’t go looking for the incidental cancers that were of no clinical significance. And if we found them, we did nothing about them. This non-treatment approach came from a Mayo Clinic study that showed a man who is diagnosed with prostate cancer had a survival curve identical to the general population of men. That was the conventional wisdom of the 1960s and it is still true today.

My credo is to treat people as citizens first and as patients second. My humanistic approach to medicine may occasionally put me at odds with my colleagues but has preserved the quality of life for a great number of men, their wives and partners. I believe that for a vast majority of men diagnosed with prostate cancer the best course of action is minimal cryosurgery or no action at all. In order to maintain a good and positive quality of life, people should stop worrying about cancer and learn to enjoy their lives. Living life to the fullest is the guiding principle by which I live my own life and the message I hope to impart to all who visit my medical practice.

Dr. Anthony H. Horan, a board-certified urologist in Delano, California. He has extensive experience in the diagnosis and treatment of adult and pediatric urological conditions. He combines clinical services and expertise with state-of-the-art therapies. He served two years in the Air Force as a general surgeon, one of them in Vietnam. After 10 years in private practice, Dr. Horan spent 15 years as a salaried urologist for the Veteran’s Administration. He has written a book The Big Scare: the Business of Prostate Cancer. Its purpose is to diminish the harm being done to our men and women by the overdiagnosis and overtreatment of prostate cancer.

What’s got lost in the public option kerfuffle

Oct 27, 2009• 9

By Matthew Holt

Not so long ago, July this year in fact, PhRMA boss and former Dem Blue Dog & Republican Billy Tauzin told the Aspen Health Forum that a straw poll of Democrats at dinner with him in DC all said that they didn’t think there’d be a public option in the final bill arriving on Obama’s desk. By the way Tauzin, Dashle, and the rest all said that there would be a health care bill passed in 2009 even though the summer of “death panels’ was just getting under way.

Now Jonathan Cohn at TNR is reporting (along with others) that Harry Reid is going to include the public option with an opt-out for states that don’t want it (think Red states), rather than the trigger (public option to come later if health care costs go up) or the co-op (moving the rest of the US to Seattle) alternatives.

This is a turn around—no question. It’s apparent that the summer of death panels actually hurt the anti-reform crowd. It’s also clear that the recent barrage from AHIP actually hurt its stated case against the public option—although as I’ve said on THCB I think that AHIP will do better with one in place.

But the problem is that this all disguises the real questions about the minor insurance reform we’re about to pass.

State of Health Care Quality: Some States Better Than Others

Oct 23, 2009• 6

Peggy O’Kane has been running the NCQA for longer than she might care to remember. NCQA is an independent, non-profit organization whose mission is to improve the quality of health care everywhere, but it’s best known for creating the HEDIS measures that rate health insurer and provider performance. I’ve been a fan of Peggy since I met her in the mid-1990s. Today she shows she’s still fighting the good fight. This is her first contribution to THCB —Matthew Holt

Suppose you’re one of the 22 million Americans living with diabetes and you have to decide where you want to live. Your choices: Providence, Rhode Island, or Houston, Texas. Providence is pretty and you’d have easy access to lobster dinners and weekends at the Cape. But Houston is warmer in the winter and just a hop, skip and a jump from a weekend in Cancun. A hard decision but you’re leaning toward Houston because, let’s face it, you hate shoveling snow!But then you take a look at the 13th annual State of Health Care Quality Report by the National Committee for Quality Assurance (plug alert: I run the place) and you find out the quality of care for diabetics is nearly 11 percentage points better in New England than it is in the South Central region of the U.S. and you begin to reconsider. In fact, you look at the newest data released October 22 and you find that the quality of care in the Texas region of the country is consistently the worst while care in New England is almost always the best. Providence here I come!

Here’s the problem: Most people don’t have a choice of moving from Texas or Oklahoma or Alabama to Massachusetts, Connecticut or Rhode Island. They have to live with the health care system they have. For a diabetic, those 11 points can translate into more kidney problems, loss of vision, toe or foot amputations or, heaven forbid, a shorter lifespan.The thing is, it doesn’t have to be this way. True, care isn’t going to be identical in all parts of the country. And, true, the population of Dallas may have a lot more health problems than the people in Hartford. But 11 points is too big a gap to explain away with demographics.