The Health Care Blog

A Bone in the Throat: The Problem with HR 3200

By JEFF GOLDSMITH

On May 12, the flame throwing Chicago White Sox pitcher Bobby Jenks was fined for throwing behind an opposing player, Texas Rangers second baseman, Ian Kinsler. When Jenks, who can throw a 102 MPH fastball, was asked about the pitch, he said, “Yeah, I wanted to go in and send a message and I think the message was sent."  When asked later if he would do it again, he said, “We’ll have to see." 

Rarely do you see that kind of candor in baseball, let alone politics for that matter.  When Speaker Pelosi and House Leadership released their version of a health reform bill, HR 3200, America’s Affordable Health Choices Act of 2009 (AAHCA), she pulled a Bobby Jenks.  Rather than put the ball over the plate, and help frame a broad consensus for health reform, Speaker Pelosi “sent a message” to the President, which was:  “We’re in charge and we will do exactly what we wish."   

HR3200 is an arrogant, tone deaf and yet oddly cowardly bill that creates, among other things, a Health Choices Commissioner to help us with our health choices.  Its message to the voters seems to be, as David Brooks put it, “98% of Americans can party on, with the latest and costliest health care imaginable, no matter how ineffectual, and the top 2% will pay for it all."

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An Update to Meaningful Use

By JOHN HALAMKA

On June 16, I wrote about the release of the draft definition of meaningful use.

Today, at the HIT Policy Committee meeting, the final definition of meaningful use was released and adopted. What was changed?

1. For inpatient CPOE, only 10% of orders must be entered electronically
2. For problem lists, ICD9 or SNOMED must be used
3. Advanced directives must be recorded
4. Smoking status must be recorded
5. Quality measures must be reported to CMS
6. Clinicians and Hospitals must implement at least one clinical decision rule relevant to a high clinical priority
7. Administrative transactions, including eligibility and claims, must be completed electronically

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Goldman Sachs, coming under fire but why should they care?

By Matthew Holt

Goldman took $13 billion of taxpayers money from AIG bailout—$13 billion which kept it alive. And it’s now back making huge profits gambling on the markets and paying out huge bonuses.

This is causing notice. Matt Tabibi wrote a wonderful article in Rolling Stone blaming Goldman for the majority of the fraud (OK, legal fraud) in the dotcom stock boom, the oil price spike, the mortgage boom & the upcoming cap & trade boom. A little taster on his blog here. Paul Krugman says essentially the same thing in his column today. And for the kiss of humorous death, here’s Andy Borowitz’ column about Goldman agreeing to take over the US Treasury—after all it’s already happened.

But the issue here is that incentives haven’t changed—other than the taxpayer has been told to give Goldman money and in return Goldman has been allowed to do what it always does. And regulations haven’t been written that will change that behavior.

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Three Initiatives to Reduce Costs and Increase Health Care Efficiencies

By DALE H. YAMAMOTO

Two major objectives underlying all current health care reform proposals are to reduce health care costs and to improve the quality of health care delivery. In my recent essay, part of the Society of Actuaries’ new essay collection on health care reform, I touched upon this health care efficiencies topic. There are three potential initiatives that may be undertaken by the government and the private sector:

• Common provider fees
• National data warehouse
• Physician council

These initiatives assume the creation of something similar to a National Health Board described in Tom Daschle’s book, Critical: What We Can Do About the Health-Care Crisis. This will to help provide input and organization on the health care reform work to be done.

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GOP to Uninsured: Drop Dead

By MICHAEL L. MILLENSON

“We are now contemplating, Heaven save the mark, a bill that would tax the well for the benefit of the ill.”

No, that’s not Senate Minority Leader John Boehner, Rush Limbaugh or any of the other usual suspects complaining about the cost of health care reform. Rather, it’s the beginning of an editorial in the Aug. 15, 1949 issue of The New York State Journal of Medicine denouncing attempts to provide every American with health insurance. Sure, 90 percent were uninsured then, versus around 15 percent, today. But what’s amazing is the way the overheated arguments by conservatives have changed hardly at all in six decades, as evidenced by an op-ed in the July 15, 2009 Wall Street Journal entitled “Universal Health Care Isn’t Worth Our Freedom.”

Here’s the August, 1949 New York State Journal:

Any experienced general practitioner will agree that what keeps the great majority of people well is the fact that they can't afford to be ill. That is a harsh, stern dictum and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor? That in order to get their money’s worth they should be sick at every available opportunity? They will find out in time that the services they think they get for nothing ­– but which the whole people of the United States would pay for – are also worth nothing.

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Preventing Extortion

By JACK CHURCHILL

The debate about a public health insurance option mirrors the debate about public power in the 1920’s and 30’s. The arguments then were very similar to the arguments we hear today.

The principal issue then was whether the federal government should enter the public power business by investing taxpayers’ money to build the Tennessee Valley Authority and to harness the Columbia and other rivers for electrical energy, or whether the sites should be transferred to the private sector. A second issue was who should build transmission lines and set wholesale prices when the Federal government built dams.

The answer to the second question was first enunciated on the Senate floor in the fight over the Wilson Dam in 1920 by Senator John Sharp Williams of Tennessee. He said, “The government should have somewhere a producer of these things that should furnish a productive element to stop and check private profiteering.” Thus was born the yardstick federal policy which later found its way into TVA legislation through the efforts of Nebraska’s Senator George Norris. In a 1932 campaign speech in Portland, Oregon, Franklin Roosevelt referred to his TVA and other regional proposals as “yardsticks to prevent extortion against the public.”

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House Health Care Reform: Ignoring the Elephant?

By ROGER COLLIER

After some frantic last minute political gyrations and a lot of pressure from the President, House Democrats have announced details of their draft health care reform bill.

Much as expected, the 852-page bill emerging from three House committees would impose a mandate on larger employers to provide insurance, impose a second mandate on individuals to obtain coverage, prohibit medical underwriting by insurers, establish a government-administered public plan to compete with insurers’ offerings through insurance exchanges, offer subsidies to lower-income individuals, and expand Medicaid. The target ten-year trillion-dollar (or more) price tag would be funded through a combination of taxes on high income individuals and reductions in some Medicare and Medicaid payments.

So, is this the answer to the nation’s health care crisis of sky-rocketing costs and growing millions of uninsured?

Probably not.

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Drug Suspected in Michael Jackson Death Subject of Recall

By SHERI FINK

Results of Michael Jackson’s toxicology tests have not yet been released, but suspicions have centered on the powerful anesthetic and sedative drug propofol, also known by the brand name Diprivan. It was reportedly found in Jackson’s house, and a nurse who worked with him said he begged for propofol to help him sleep. 

Now, some lots of propofol are being recalled for contamination.

Last night, the Centers for Disease Control and the Food and Drug Administration advised clinicians immediately to stop using propofol from two lots found to be tainted with elevated levels of endotoxin, a toxin made by bacteria. Regulators said Teva Pharmaceuticals, the manufacturer, had begun a voluntary recall of the lots.

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Eliminating Medication Waste in Long-Term Care Can Help the White House Pay for its Health Plan

By CARLA CORKERN

The news of an $80 billion White House deal with drug companies to lower Medicare drug costs targets $30 billion in savings for consumers covered by Medicare Part D, but the sources of the remaining $50 billion in savings that is supposed to accrue to the government “have not been identified at the moment,” according to an Administration spokesperson.

With the Administration scrambling to find ways to pay for a much-wanted healthcare package estimated to top a trillion dollars in just 10 years, every few billion in potential savings counts.  That’s why the government should take a close look at the extraordinary amount of medication waste that is literally flushed down the toilet every year in long-term care (LTC) facilities.

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Op-Ed: Healthcare Reform Lessons From Mayo Clinic

By LEONARD L. BERRY and KENT D. SELTMAN

Three goals underscore our nation's ongoing healthcare reform debate:1) insurance for the uninsured, 2) improved quality, and 3) reduced cost.  Mayo Clinic serves as a model for higher quality healthcare at a
lower cost.

President Obama, after referencing Mayo Clinic and Cleveland Clinic, advised, "We should learn from their successes and promote the best practices, not the most expensive ones."  Atul Gawande writes in The New Yorker, "Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country-$6,688 per enrollee in 2006."

Two pivotal lessons from our recent in-depth study of Mayo Clinic demonstrate cost efficiency and clinical effectiveness.

1. Patient-first medicine.  Throughout its 140-year history, Mayo Clinic has never put money first but lives its primary value:  the needs of the patient come first.  Mayo doctors, as all employees, are on salary.  No doctor earns more by ordering an extra test or procedure.  No doctor earns less by referring a patient to another Mayo physician with more expertise.  

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Schwarzenegger replaces most of state nursing board

By TRACY WEBER AND CHARLES ORNSTEIN

Gov. Arnold Schwarzenegger replaced most members of the California Board of Registered Nursing on  Monday, citing the unacceptable time it takes to discipline nurses accused of egregious misconduct.

He fired three of six sitting board members – including President Susanne Phillips  – in two-paragraph letters curtly thanking them for their service. Another member resigned Sunday. Late Monday, the governor's administration released a list of replacements.

The shake-up came a day after the Los Angeles Times and ProPublica published an investigation finding that it takes the board, which oversees 350,000 licensees, an average of three years and five months  to investigate and close complaints against nurses.

During that time, nurses accused of wrongdoing are free to practice – often with spotless records – and move from hospital to hospital. Potential employers are unaware of the risks, and patients have been harmed as a result.

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Eliza gets a nice write up in BusinessWeek

BY MATTHEW HOLT

Indeed, it’s so nice that methinks Lucas & Alex were quite seductive! Speaking as a friend and one who’s been indoctrinated into the cult of Alexandra Drane, its interesting to see the mainstream press picking up the “phone as a tool” theme. The BusinessWeek article shows that a) these calls work to change behavior if targeted correctly and done well and b) that Eliza is humming along very nicely financially. What it doesn’t hint at, but is well worth considering, is the vast potential for these calls to collect data from patients as well, as to relay information to them. As you may guess you’ll see more from Eliza at Health 2.0 this fall, and you can be sure that we’ll be hounding them on that latter point.

Costs Are Not The Same As Rates

By PAUL LEVY

Many "old" media outlets do not identify the authors of their editorials. Thus, when an opinion is offered, you have no way of knowing who wrote it or what their qualifications are. Your only recourse when there is something unsupported or absurd used to be to send a letter to the editor, where you have about a 0.5% chance of being chosen for publication. And they would edit what you sent in. Then, blogs were invented.

This thought was prompted last week when I read a New York Times editorial entitled, "Financing Health Care Reform." Here's the quote in question:

Meanwhile, it will be important to get some guaranteed fast savings from the health care industries by cutting and reallocating hundreds of billions of dollars from projected spending on Medicare and Medicaid, as the Obama administration has proposed and Congress is considering. Just to be sure, Congress ought to establish a fail-safe mechanism that could impose additional cuts after a few years if savings are less than projected.

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Op-Ed: Forward thinking health plans? Look for the guys with the white hats

By RICHARD NOFFSINGER

The public noise about health care reform has painted the parties involved in broad brush strokes that tell  consumers which in the fray are the good guys and bad guys. News reports have for so long vilified health insurers that they’re overlooking the forward thinkers who are actively seeking the white hat role and using their heft for real and positive change.

With the near-term incentives to spur adoption of EMRs and subsequent implementation of clinical decision support to make those EMRs “meaningful”, health plans have a perfect opportunity to improve their value. I already see that happening with our health plan customers who have used additional means to improve their populations’ health, such as personal health records, disease management, and other strategic initiatives.

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The Case for Comparative Effectiveness Research

By RAHUL PARIKH MD

When I was a kid growing up in Los Angeles, there was this local TV show my dad used to enjoy  watching called Fight Back with David Horowitz.  Basically, Horowitz, a TV reporter and consumer advocate, used to put the claims a manufacturer made about their products to the test—whether it was if Samsonite luggage could withstand abuse from a Gorilla or Bounty really was the “quicker picker upper,” it was on its show and ended up either endorsed or debunked by it.  It was Consumer Reports come to life, if you will—pitting products against one another to see which one was worth putting down some hard earned dollars for.

Now, over 30 years later, we in medicine are just getting around to doing the exact same thing that Horowitz was with retail way back in the 1970s—comparing the claims made by drug and device makers about their products.

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Nursing Homes Get Old for Many With Disabilities

By JENNIFER LaFLEUR

ST. LOUIS -- Melody Ping never thought she would be trying to moveout of a nursing home. She lived in a St. Louis apartment for 19 years and worked as an accountant until two years ago, when she lost her job. Ping, who has multiple sclerosis, couldn't find new work. When her unemployment ran out, she ended up on Medicaid in a nursing home.

Ping, 51, is among tens of thousands of people nationwide who want to live on their own, but instead remain in nursing homes, rehab centers or state hospitals, often at a higher cost to taxpayers because of a historic bias toward institutional care.

Ten years ago today, the U.S. Supreme Court said that bias amounted to discrimination. Now, as disability advocates celebrate the anniversary of that landmark ruling, they worry the Obama administration is backing away from a pledge to give more people with disabilities the option to live at home.

As a senator, Barack Obama co-sponsored the Community Choice Act, pending legislation that would give Medicaid recipients equal access to services in the community and not force them into institutions. But the administration recently said it would not address the issue as part of its proposed health care overhaul.

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Musings on Payment Reform

By CHARLIE BAKER

Charlie Baker is the president and CEO of Harvard Pilgrim, a nonprofit health plan that covers more than 1 million New Englanders. Charlie is a regular contributor to THCB, where he has authored posts on national health reform (See: "Is Massachussetts a Model for National Reform?"  and related issues facing the healthcare sector. (For example: "Shifting Costs From Public To Private Payers"). His posts also appear at his own blog, Let's Talk Health Care.

This week Charlie confirmed a longstanding rumor, announcing that he will be giving up his position at Harvard Pilgrim at the end of July to run as a GOP candidate for governor of Massachusetts. You'll find more about his campaign on his web site, CharlieForMA.com.

The Commonwealth of Massachusetts - along with a number of other states (including New Hampshire and Maine) and the federal government - is kicking around a number of ideas concerning payment reform.  The argument goes something like this - since the current health care system, led by the gigantic Medicare program, pays primarily on a fee for service basis.  This “do something” payment model encourages clinicians and hospitals to do “more” for patients than they might do otherwise, if they weren’t encouraged to “do something” to get paid.  Add to that the fact that fee for service - again led by Medicare - pays more for new technology than it does for existing technology, and less for primary care, and you have the primary ingredients in the recipe that’s driven our system to be technologically driven, volume driven, fragmented and very expensive.

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Behind the Curtain: Wendell Potter on the Industry's Management of Care and Reform

By BRIAN KLEPPER

Stop what you're doing and take out a half-hour to watch this week's superb Bill Moyers' 3-part show, especially the extended interview with Wendell Potter, former CIGNA VP Corporate Communications, for a frank, insider's discussion of how major health plans have worked over the last decade.

Also be sure to watch Moyer's very brief final commentary, describing a dinner that was planned by the Washington Post to connect lobbyists with high-ranking officials working on the health care reform process. His conclusion: we won't get anywhere with health care or any other national problem until "the money-lenders are tossed out of the temple and we tear down the sign they've placed on government, the one that reads 'For Sale.'"

Announcement: 14,000 People With Diabetes Test Their Blood Sugar at the Same Time

July 14 at 4 pm ET, 14,000 people with diabetes are going to test their blood sugar simultaneously and share their results online to help raise diabetes awareness.  People with diabetes have to test their blood sugar as part of their daily routine: it’s like drinking water or brushing your teeth.  Participating is easy: if you are a member of TuDiabetes or EsTuDiabetes, click on the home page banner and share your reading; if you have a Twitter account, post your reading on Twitter (use the #14KPWD hashtag) and link back to: http://14kPWD.org; if you prefer, update your status on Facebook or your preferred social network, linking back to: http://14kPWD.org. If you are a few minutes late, however, or are able to post your blood sugar reading earlier or later that day, it’s OK. What really matters is that you test your blood sugar regularly. If you don’t have diabetes, just tell someone who does to test and share on July 14.

Fantasy League Baseball -- Beltway Series Edition

By MICHAEL MILLENSON

Bob Laszewski’s Health Care Affordability Model has the same connection to the reality of the current  battle over health care reform as a Fantasy Baseball League does to the actual outcome of a major league baseball game; i.e., none.

 Actually, while those who play Fantasy Baseball – might we call them “baseball wonks”? – are affected by what happens in the real world to the players they have selected, they have no illusions of reciprocity. Laszewski is a brilliant analyst whose examination of the various political proposals for health-care reform have become a “must-read.” But in making his own proposal, Laszewski, a strategy consultant based in Washington, has managed to completely ignore the fact that reform is an intensely political process.

 “The Health Care Affordability Model…could be attached to virtually any health care reform plan now on the table,” he writes.

 No, it couldn’t. Just like managing a Fantasy Baseball team has no connection to managing real major league players. Given Laszewski’s timing, his proposal is somewhere between almost irrelevant and completely so. Which is not to say his ideas are wrong.

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Has Harry Reid Torpedoed Reform?

By ROGER COLLIER

Health care reform ran into new BIG trouble this week with a series of comments from Senate Majority Leader Harry Reid.

On Tuesday, Reid leapt into the middle of reform negotiations, telling Senate Finance Committee Chairman Max Baucus that Democratic leaders had major concerns about the draft Senate Finance bill’s proposed taxation of some health benefits and the exclusion of a strong public plan.

The immediate result was the effective suspension of bipartisan negotiations on the Senate Finance draft, with Republican Senators Chuck Grassley and Orrin Hatch both saying that bill markup would have to be delayed indefinitely until the conflict was resolved.

Yesterday, Reid tried to soften his comments in conversation with Senate Republicans, but later indicated that taxing health care benefits was still unacceptable, leaving Senate Finance members wondering how else to help pay for the trillion dollars (or more, perhaps much more) that they estimate as the ten-year cost of reform.

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Why Congress Should Consider Bob Laszewski's Health Care Affordability Model

By BRIAN KLEPPER

Over the last few months, I have become increasingly disheartened over the prospects for meaningful health care reform.

First, the process is terribly conflicted, and it shows. In the first quarter of 2009, the Center for Responsive Politics reported that the health care industry contributed $128 million to Congress. Now that the tide has turned, this has gone mostly to Democrats who, as it turns out, are just as receptive as their Republican predecessors.

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The Affordability Model

By ROBERT LASZEWSKI

Most health care experts agree the reason our system is so unaffordable is because of all of the waste  and unnecessary care—up to 30% of what we spend.

I will suggest that it will take the genius of individual creativity to separate the 70% of this health care system that is the best in the world from the 30% that is waste.

So far, the Congress has focused more on entitlement expansion then fundamentally reforming the system and tackling the real problem—getting all the excess costs out. The result so far is expensive health care proposals and no real reform.

How can we actually make the health care system affordable as we expand coverage? I will suggest a three-pronged attack:

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