Jul 29, 2009

Social Security and Medicare: Where to find the law itself.

For my class of '62 (hs) and '66 (college) cohort, and all those older and slightly younger : Here is a link to the Social Security and Medicare Laws. I like it because, though it's almost unreadable, you can search within the page to find what you want... for example, payment for home health services.. search "home health".. Then, references to other sections of the law are highlighted with clickable buttons. Yes, I agree that you'd have to have no life at all to want to research the law on a specific issue that you might have with Medicare, but you never know when that will be true! And think of how popular we'll be in the nursing home with our laptops to help our fellow inmates (or their children) figure out how to get reimbursed!

Jul 27, 2009

Canada to study Vitamin D and Swine Flu!

One of the things I learned from doing medical technology assessment is that Canada is a country filled with epidemiologists. Even family practitioners get masters degrees in epidemiology. At conferences, they introduce themselves as "family practitioner and clinical epidemiologist." In the USA, by contrast, epidemiologists are often considered the weirdos of the medical profession. (Why would anyone waste their precious brains on such dumb stuff when you could be stapling stomachs?) Epidemiology is the systematic study of disease in populations. Not the study of stapling technique in gastric surgery.
So, I guess I should not be surprised that the Canadians have taken the lead in using the current Swine flu epidemic to examine the link between flu severity and VITAMIN D! Just learned from CIDRAP (my favorite source on everything infectious, run by American epidemiologists, of course) that the Canadian Public Health Agency will be testing people with Swine Flu for their Vitamin D levels to determine whether those who do badly have lower levels. The Toronto Globe and Mail had a very nice article on it. Canada's press release was a little broader than just Vitamin D, since they'll also be looking for genetic factors. But, the very fact that they will actually use the current epidemic to get some info on Vitamin D and influenza is a reflection on the sophistication of Canada's approach to health research and policy. If Vitamin D actually turns out to provide some protection, as some scientists believe, it's the kind of low hanging fruit for cost-effective medicine that we need if our President's promises of lower cost health care are ever to be remotely approached. (He should stop promising that, anyway.)

Jul 22, 2009

The "Public Plan" and Health Reform - What's wrong with it?

Health reform legislation is now focusing on building a regulated marketplace (or exchange) for plans to offer insurance to individuals. The regulations would require health insurers to offer a standard set of benefits at a single (or at most age-specific) premium and to take all comers, even those of us who actually will need medical care in the near future. The idea would be that you can choose among, say, 10 plans all offering a mandated set of benefits, but perhaps varying on co-pays, deductibles, and choice of providers.
A marketplace of competitive -- but regulated -- health plans offers the best hope of reaching a reasonable balance between costs, access and quality of medical care, because consumers (that's us) would be able to exercise the strongest vote possible against a plan that skimps -- select another! Same with a plan that costs too much. Over time, plans would come to look more and more alike. But, most important to my mind is that a competitive program would hasten the integration of medical care delivery into systems of care. That's where hospitals, physicians and other providers get together to offer a health plan in which they share the savings that come from making care more rational and cost-effective. (And, in every open season, they'd have to give some of those savings back in reduced premiums in order to stay competitive.) Integrated health delivery systems can be larger than one city or county. They can involve arrangements with nationally recognized high-quality cancer centers, for example, to offer state-of-the-art care. You might be willing to pay a bit more if your plan included access to the best specialty centers for certain types of care. Most important, integrated health systems would have to compete against rivals on both quality and cost.
The current fee-for-service system is a drag on system integration, because doctors are paid piecemeal and do not benefit from talking with one another or investing in more efficient use of hospitals and technology. It's a dinosaur payment system.
How does the public option come into all of this? The public option is essentially a Medicare add-on. It will piggy back onto the Medicare fee schedule and fee-for-service piecemeal payment system. So long as it pays physicians enough to keep enough of them accepting public option patients, it will be a drag on the needed evolution to systems of care. It will perpetuate the disjointed, disconnected, dysfunctional, and dissed (by me) current system.
That's my main problem with a public plan. Even one that pays doctors generously (and therefore gets buy-in from the altruistic American Medical Association) is likely to gum up the works for real reform of the health care delivery system for a long time to come.

Become a Medicare Expert in 2 Minutes!

A little-known federal government Commission, MEDPAC, is a fount of information and advice about how to fix Medicare. (A lot of its advice I do not agree with!) It's staff is small (about 30 people) but its knowledge of Medicare is deep. The reason it's not known by most of us is that it works for the Congress, not as an educator of the general public. But, last week they put out a great Data Book: Health Care Spending and the Medicare Program, that summarizes very nicely exactly where our Medicare dollars go and why everyone in Washington with at least a smidgen of patriotism (versus self-interest) is semi-hysterical over the "Medicare problem." All you have to look at is the first 15 charts (in chapter 1 of the report) to understand why Medicare fee-for-service -- fee schedule -- medicine has NOT protected us from breaking the bank! The other 200 pages would be interesting for obsessive compulsives, but as imminent or new Medicare beneficiaries, my fellow classmates and I should at least know the basics. And, if we're still going to cocktail parties, we can spout a data point or two and be considered an expert!

Jul 21, 2009

How to Contact the White House

http://www.whitehouse.gov/contact/
My friend G., who volunteers at the White House's phone bank, says the White House actually DOES methodically monitor the content and views of its incoming calls, except for total cranks whose expletives deleted are hard to categorize. So, I'm sure they're doing the same with their E-mails.

Goldman Sachs' Perfidy????

Love that word -- perfidy? I'm not sure I'm using it correctly, but out it jumped, keeping me out of the nursing home for another week. But, that's another story.
Sister Janet alerted me to an article by Matt Taibbi in Rolling Stone Magazine (of all places) on Goldman's role in every major bubble-meltdown since the Great Depression (ours today is only the Great Recession). Today in the Washington Post, Alan Sloan tells how Goldman is arguing with the Feds, which saved its hide in the past year, over how much our (i.e., US taxpayers') stock warrants are worth. Sloan thinks Goldman is tacky and greedy. We should contact the White House with a simple E-mail -- "Make Goldman Pay!" It's easy to do that...Click Here!
My friend G., who volunteers at the White House's phone bank, says the White House actually DOES methodically monitor the content and views of its incoming calls, except for total cranks whose expletives deleted are hard to categorize. So, I'm sure they're doing the same with their E-mails.


Then, somehow, we should keep track of what Treasury does. I'll try, but if you happen to see it in the next few weeks, leave a comment at the end of this post, and I'll pick up on it.

Jul 9, 2009

Health Reform- Capping the Employer Tax Benefit

To me this is a no-brainer. Right now, the government subsidizes employer-provided health benefits by about 35% (the corporate tax rate). That creates a huge incentive for companies to provide rich health benefits for employees who might otherwise choose to opt for less generous coverage (higher co-pays, etc), and get higher wages instead. Less generous coverage would make employees use health care more sparingly (YES! We need to do that), which would lower health care costs.
Fortunately, an op-ed in the Washington Post by Len Burman (of the Urban Institute, and once a CBO analyst) makes these points much more convincgly than I can, so here's the link to "Give Up a Benefit, Get a Job."

Jul 7, 2009

Health Reform Kennedy Style

While I'm still pondering all the ramifications of having a public (Medicare-like) plan offered along side competing private plans under a Health Reform PROGRAM, I must share with you my reading of the first 200 pages (Title 1) of the latest version of the Senate HELP Committee's draft legislation. (I read so you don't have to!) (If that doc doesn't open, it means it's already been updated, so go to the Senate HELP Committee's home page to find the latest.)
One item I find particularly delightful is the provision to extend Medicaid eligibility to all individuals in households with incomes below 150% of poverty-- that's about $35K a year for a family of 4, covering about 18% of all households in the USA, according to Wikipedia.
On its face, that's not so terrible, since State Medicaid agencies are very very careful about how they spend money for Medicaid recipients. (States must pay for about 43% (on average) of total Medicaid spending. The Feds pick up the rest.) Indeed, some might say they're downright stingy! Here's the little detail: the legislation provides for the States to continue to administer the Medicaid program for those new enrollees, but this time the FEDERAL GOV'T will foot 100% of the bill. So, say you're the Governor of your state. What would you tell your Medicaid Director to do? Give 'em the BEST! Pay those doctors more! Stick it to the other 49! Of course, the other 49 will stick it too, so The COSTS, THE COSTS! They'll be out of control, and I'll probably want to qualify for Medicaid!
These are the kinds of little goodies that make me almost despair of ever getting affordable health reform. (Ironically, "Affodable Health Care" is the name of the HELP bill.) Bottom line: THANK GOD FOR CBO! I'm sure they'll cost it.

Jul 3, 2009

Three most important health reform questions

To my mind, the three most important issues in the design of a new health reform program are these:

  1. should employer plans enjoy unlimited tax deductions for health benefits; and should employers who don't offer insurance be taxed?
  2. should all uninsured people be forced to enroll, and be taxed (or jailed...just kidding) if they go uninsured? (Too poor? That's where subsidies come in.)
  3. Should there be a Medicare-like public plan offered along-side the competing private plans in the regulated marketplace that would be set up under the program?

I'm sure my former colleagues at CBO at dealing with many more questions than these, but these are the three that will determine whether we ever get a viable program that actually covers all Americans without ruining the health care system in one way or another.

I'm going to start with question number 3 in my next blog, because I'm most confused about it. I started out VERY certain about what the program should look like in this regard, but the more I think about it the less certain I get. Next post will try to lay out the pros and cons of that.