The View from Bethesda

Vitamin D and heart disease - suggestive evidence

2011-11-30T10:46:00.000-05:00

Medline Plus (NIH) just had a news release about a large study of Vitamin D supplementation and heart disease. Shows huge effects. This is a prospective but NON RANDOMIZED study, so as with so many such findings, it may not pan out. Back in the day, we studied estrogen and heart disease (at OTA), and the large prospective studies showed that estrogen replacement therapy had huge effect on subsequent heart disease. Too bad, about 10 years later the evidence came out that ERT actually increases heart disease.
So, I am including the news release here just to track what later evidence reveals.
Medline-Vitamin D/Heart Disease

US Bankruptcy Code Downloadable

2011-11-25T10:04:00.000-05:00

Just in case, you never know, when you need to be a friend's lawyer-equivalent, and have lots of time to interpret more arcane laws, here is a link to the US Bankruptcy Code, available in readable format, made available through US Credit Slips web site.

The newest Republican Front-Runner

2011-11-19T15:36:00.001-05:00

I just had to post this to get some relief from the idea of Newt Gingrich as the Republican nominee. The Borowitz Report had the scoop.

Gingrich says CBO must go.

2011-11-17T08:51:00.000-05:00

Why I'm taking Gingrich seriously, knowing what I know about him from my CBO days, is a mystery to me. I guess it's just that I worry about who the Prez might be if not Obama. So, here he is at his most Gingrich, espousing the death of CBO BECAUSE OF ITS HEALTH WORK! Neat! Thanks to the CBO alumni group for alerting me to this. Link to Stan Collander's article is here: http://capitalgainsandgames.com/blog/stan-collender/2416/newt-gingrich-wants-kill-cbo

First RCT of Vitamin D supplementation in MS shows no benefit of high dose.

2011-11-11T21:41:00.001-05:00

Recently reported in Neurology (and available to the public) this was a small trial of short duration of patients with established MS. Nevertheless, it shows no benefit, and the direction of effect was towards harm, though it was insignificant. So, while Vitamin D deficiency appears to be causally related to onset of MS, high-doses of D, which raise blood levels to 40ng or more, don't appear to help. An interesting "patient page" lays out the strengths and weaknesses of the study.

More environmental hazards of Fracking showing up.

2011-11-10T17:53:00.000-05:00

ProPublica's latest report on the inability of the fracking industry to protect our aquifers. What a surprise!

The best summary of the causes of the financial crisis

2011-11-07T09:33:00.001-05:00

The Washington Post's Sunday business section had a wonderful piece by Barry Ritholtz on the causes of the meltdown: The Big Lie.
He could have made more of the long-running idiocy of the SEC that anointed the three ratings agencies (S&P, Moodys and Fitch) as the only "nationally recognized" sources of bond ratings, thereby requiring pension funds and insurance companies to rely on those ratings for SEC compliance, and at the same time taking the pension fund managers off the hook for failure -- "What else could I do? I had to rely on the ratings agencies. Besides, if I had to do more work, I wouldn't have been able to go home to my beautiful family and our house in the Hamptons (or Martha's Vineyard, take your pick) on the weekends."

Here's some charts he put up on his web site as of 11-20-2011. Ritholtz Charts

Largest increase in greenhouse gas emissions in 2010, a recession year

2011-11-04T19:43:00.000-04:00

This Time Magazine article summarizing the latest findings from the U.S. Department of Energy also has photos of the results of global warming that make it hard to sleep.

Vitamin D's role in prevention of infections becoming clearer

2011-10-18T20:28:00.001-04:00

This time it's TB. See the Medline news article for more detail. All the more reason to keep track of your vitamin D status this winter. The only problem with this article: what is "sufficient" level of Vitamin D? I'll have to research and amend this posting.

The state of the global economy, by Joseph Stiglitz

2011-09-30T09:29:00.000-04:00

Much has been made of his nobel prize in Economics, but let's face it...there are now a lot of those running around. Nevertheless, I always find his papers and remarks understandable, which is a big thing in my view.
Here he has a sort of radical idea for saving the world economy, and he also puts the "state of" in an excellent perspective.
Here it is: Stiglitz World Bank Talk

Everything you ever wanted to know about molds on foods

2011-09-26T13:49:00.000-04:00

Here is a CDC summary of the dangers of eating moldy foods -- even a little pinprick's worth.
And who said our taxpayer dollars don't produce anything useful?

A vivid example of the dangers of Fracking

2011-09-16T20:09:00.000-04:00

Is there any such thing as "adequate" regulation of an environmental hazard? My friend with an insider's knowledge of FDA says no, and she peppers me with stories about how politics have made the job of reviewers difficult. (Her experience dates back to the Bush years, so I calm myself by thinking that all of this has changed since the new leadership at the FDA has arrived. (Some of those higher ups are holdovers, however, so why should I think they've changed their spots?)
Well... this post is about hydraulic fracking, the environmental issue du jour for Pennsylvania, New York and Maryland. Here is an article about some of the health problems that westerners in the path of fracking have experienced, brought to you by ProPublica, that innovative on-line source of investigative journalism.
Of course, I sit here with my new hip, wondering whether it's one of those metal-on-metal things that are failing at a rate of about 29% so far (based on British data...we Americans don't have registries, being ostriches as we are). So, maybe FDA is more important than the future of the planet.

Find your Congressman on Twitter

2011-09-12T18:19:00.001-04:00

Here is the list of Twitter Addresses for members of the House of Representatives.

If you use Twitter, it might be a good way to send your opinions in. Short and sweet.

Dems help keep low tax rates on wealthy.

2011-09-12T12:07:00.001-04:00

We expected it of the Republicans, but this Washington Post Article reviews the voting patterns of many Democratic legislators (and President!) who created and protect the very very low (now 15%) capital gains tax. Only the wealthy have substantial capital gains that are not sequestered in tax-deferred or tax-free IRAs or 401-Ks. It takes a wealthy person to benefit from the low capital gains tax. If we need to raise revenue, we should start there.

How bad is your State's credit risk?

2011-09-04T15:37:00.000-04:00

Barron's has a great article this month on the state of our States' credit ratings. Whether you're an investor or not, it's worth a look to see how your own State fares in the "best" list and the "worst" list. After all, in the end the taxpayer will pick up the tab, and that's all of us one way or another.
Little Delware (the Blue Hen State) turns out to have the strongest credit position among all states. How do they do it, considering that they must spent gadzillions rebuilding the beaches every spring to keep the ocean from washing it away?
I very much like the layout of criteria for assessing a State's credit health. Hope this link to the article works. Good, Bad and Ugly. If not, go directly to Barron's and search for the article.

Imagine the USA without regulators of gas pipelines.

2011-08-05T19:56:00.001-04:00

When your TeaParty friend starts up again this fall, calling for deep federal discretionary spending cuts, here's a great example to (figuratively) shove in her face of an industrial regulation that we may not be able to live without.
This gas pipeline example involves faulty welds holding together the Millenium Pipeline Company's line through the southern tier of New York State. Cities I know well -- Spencer, Oswego to name two --are in the pipeline's path. For a map of the track of the pipeline through New York's southern tier, see NaturalGasWatch.org.
ProPublica has a good article on how bad the situation with the pipeline is. If you know people who live in the southern tier of NY State, pass this information on.
We should start a catalogue of federal government "discretionary" programs that are endangered by steep budget cuts. I betcha our teaparty friends would say, well, of course not THIS program, but the other, wasteful, programs are the ones that need to go. Or, maybe they would say this is just an outlier situation that the company will handle on its own quite nicely. (I wish the company had addressed the issue somewhere in its web site. I would sleep better at night on behalf of my friends in Oswego and Spencer if I thought the company was taking safety issues seriously enough to inform the public.)
We middle-of-the-roaders should start to catalogue federal discretionary programs, especially regulatory ones, that are worth their costs beyond a shadow of a doubt. And, ask our teaparty friends to start listing the specific programs or regulations that are not worth their costs. Let's see what we all come up with.

Details of the Budget Deal in (sort of) plain language

2011-08-03T19:30:00.002-04:00

CBO's cost estimate lays out the essence of the provisions, and also a concise description of how the process going forward will work. Even better is the CBO Director's Blog. There is no mention of the CPI change as described in my previous post. So, that provision appears not to be in the current agreement. Perhaps it will come in the next one, if there is ever an agreement at any time ever again over anything.

The budget deal will include a hidden Social Security benefit decrease

2011-07-31T14:24:00.005-04:00

[Update Note 8-3-2011: This provision was not included in the Budget Agreement of 8-1-2011. It may come up again in the further cuts implied by the agreement.]

I'm not against the benefit decrease that I'm about to explain. It's relatively minor. But, it's emblematic of the snookering job our pols give us through legislative deals that are too arcane for us to understand.   When the Pols tell you they haven't touched Social Security or government pensions with the deal now in the making, you can say, "sure, buddy,...just keep passin' the kool-aid so's I can drink."
My trip to Wegmans yesterday to buy raw frozen shrimp for a casserole will explain all, if you stay through the arcania of the next paragraph or so.
In a nutshell, the budget deal will change the basis for the annual COLA update from the current Consumer price index (CPI) to a Chained Consumer Price Index (C-CPI). I've heard several experts, including democratic pundits (see NPR program), say that this is a "more accurate" way of measuring the update than is the standard CPI. I say "Hooey".
The government calculates the CPI each month by using a careful sample of a defined "market basket" of goods and services that consumers buy to keep themselves going. This market basket is set every 5 years or so.  It includes our purchases, ranging from toothpaste and broccoli to automobiles and housing.  The price of each component in the market basket is measured each month, and the overall CPI index value is based on the price today as a ratio of the price in a base year (say 1983) for each item. Every item in the sample is weighted by its percentage of spending in a "weighting year," which is different from the base year. Though the weighting years change from time to time, years can go by before new products are added into the market basket and new weights are calculated.
The weighted average in a particular base year (say, 1983) is given an index value of 100, and today's value is calculated as the current weighted average of prices divided by the weighted average of prices on that base date.  The CPI for 2010 was 218 (compared with 100 in 1983). That means that prices more than doubled in the 28 years from 1983 to 2010. (See The Economic Report of the President 2010 for a table of CPI over the years.)
The chained CPI plays with the weights in a way that lowers the measured CPI.   Here's how.  Whereas the regular CPI uses weights for some prior year -- say, 5 years ago -- which reflect the choices consumers made among all these items back then, the C-CPI keeps changing the weights to reflect the current distribution of expenditures across items. So... let's say that the price of one item goes up radically while the prices of all other items increase only slightly. What usually happens is that people stop buying so much of that item and its weight in the index declines while others go up. Best example is steak vs hot dogs. Let's say the price of beef is going up faster than other things (due to all those Chinese rich people who suddenly want to get fat on steaks). Now, instead of our tasty filets every Saturday night, we have a nice hot dog with kraut and ketchup.  We aren't thrilled, but we adjusted, right? And we lived within our budget. Our quality of life has gone down, at least by a smidgen. And lots of us do this, so that the value of steaks in our market basket today is now lower than it was last month. So, the government "rewards" us by reducing the weight placed on the price increases for steaks and increasing the weight on all other items, including hot dogs, which haven't increased so much.
One expert, Dean Baker, says that this switch to the chained CPI will likely reduce social security and other pension benefits with COLAs (e.g., federal employees) by about 0.3% a year, or roughly 3% over 10 years. That's not very much, and it's the result of our resilience as Americans in learning to cope with adversity. But, IT IS A REDUCTION IN BENEFITS! So, don't let anyone -- Dem or Republican or TeaParty -- tell you that you haven't already given.
Now to Wegmans and my shrimp. I have a very good recipe for Sullivan Island Shrimp, which needs a pound of raw shrimp. So, I went to Wegmans, found a bag of frozen raw shrimp, couldn't find the price, and finally with help learned that 2 pounds would cost me 29 bucks. I couldn't believe it. Rechecked. Sure enough. Well, just six months ago, I could get 2 pounds for about 16 bucks. After much back and forth -- I put it in my cart twice before finally putting it back -- I decided that the nice chicken pot pie in my freezer would do just fine. "Wow!," I thought. "I've reached that point -- can't (or don't want to) afford my signature shrimp dish. Oh, well, I'm coping." And, of course, I'm helping the government reduce my social security payment in the coming year.

Vitamin D and Diabetes: New evidence

2011-07-12T18:18:00.001-04:00

It appears that vitamin D supplementation may help with pre-diabetic conditions. See the news item from the National Library of Medicine's Medline Report.

Tales of Two Fracking States: PA and MD

2011-04-01T13:08:00.001-04:00

I just read a ProPublica report on Pennsylvania's department of environmental protection's new rule requiring inspectors to get all violations of natural gas drilling operations approved by the head of the agency. Implication: this is bad for the environment. But I'm not so sure. If human being regulators are susceptible to corruption, isn't it better to have one central actor to blame when the stuff hits the fan? Having a lot of manipulatable inspectors with the power of the citation is not my idea of responsible regulation. Nevertheless, PA seems hellbent on sucking the stuff out of the bowels of the earth.

Maryland, on the other hand, is delaying, studying, etc., according to the Washington Post's article a few days ago. Will that be any better in the end?

Oh, we of little faith -- science is our hope. science is our folly. Which?

Natural gas Fracking in Pennsylvania could ruin New York's Finger Lake

2011-02-27T17:23:00.001-05:00

Friend Mary let me know that today's New York Times Article on natural gas fracking wells and their impact on the environment is a must read for anyone who loves the still relatively pristine beauty of New York's Finger Lakes, particularly Cayuga.
Put it together with the ProPublica report mentioned in my previous post, on what the fracking technology has done to water in Wyoming, and it's scary that, once again, we seem unable as a society to limit our use of energy and abuse of the environment.

Fracking for natural gas, or conserving at the pump?

2011-02-26T11:25:00.000-05:00

The new fracking technology proposed by the natural gas industry promises to reduce energy costs in the near term, but at what cost to the environment? Fracking began in the US in Wyoming, and the current action is in Pennsylvania, New York State, and even Maryland. Here is a ProPublica article on the impact of fracking on fresh water in Wyoming. It's long but gripping.
Meanwhile, I'm cheering the rising price of oil, due to international events and China's demand, which may lead us Americans to start conserving at the pump. There's nothing like $4.50 a gallon to get one to start thinking about high-mileage cars. A gas tax that would get us there-- coupled with fixed dollar relief through payroll tax holidays and social security checks -- is what I think is the only sensible long-run energy-related response to so many problems: balance of payments, federal deficit, national security, and global warming,
Especially if you live in New York, Maryland or Pennsylvania, and are alarmed by what's happening in the shale bed regions of those states, you can pass on the Propublica article. People should start contacting their state legislators about this before it's permanently too late.

ProPublica is an on-line experiment in investigative journalism that is independent and thorough. You can subscribe to email alerts -- I do.

Here's a great information source on Vitamin D.

2011-01-22T09:00:00.001-05:00

My last blog, about the IOM's new recomendations, led to a comment by one Henry Lahore, who has taken upon himself to keep a "Vitamin D Wiki" site. I checked it out. It is a truly amazing source of info on the latest research on Vitamin D. I don't know HL, but in his "about us" he says he's a retired engineer who seems to be doing this for fun and not money, just like I am. I am thrilled to have found this site, as I am not nearly as disciplined and complete as he has been. I'll register for his site, and if you're as vitamin D-obsessed as I am, you can too. But, I'll also post interesting stuff that I find on his site here, hopefully giving him full credit for alerting me.

An Expert's Comments on IOM Vitamin D-Calcium Report

2011-01-21T09:10:00.003-05:00

Digesting the IOM's recent report on recommendations for calcium and Vitamin D seems to be as difficult for me as absorbing Vitamin D itself. I'm on the second read, word for word. I'm not a trained nutrition scientist, but I know a bias toward the null (i.e., no benefit) when I read it. Still, it's reasoned and thorough, so I've been reluctant to comment, as I know a bias toward the positive (my own) when I feel it.
But, here is a comment in the Newsletter of the Harvard School of Public Health put out by two leading researchers on nutrition, one of them a legendary figure in nutrition and epidemiology, Walter Willett. It rings true to me. Let me know what you think.

More on GE and its quality control

2011-01-20T10:57:00.002-05:00

Friend Lupi enthusiastically supported my conclusion about GE in a previous blog. Here's what she had to say about her own experiences:

Loved your comments on GE appliances. We will never buy another GE appliance again. We wouldn’t take one as a gift. Here are my 2 favorite stories. A year after we got our (installed in cabinet) GE microwave, the interior light went. We were also having trouble with our GE oven, so I asked the repair person to replace the light (John having been unable to figure out how.) He told me that it would be good if I could do without the light because there was no way to replace it without removing the entire unit from the wall and that would involve a service call with 2 workers. I was so steamed I wrote GE suggesting that the engineer who had designed this model be fired. No response, of course. Next the GE dishwasher. The cup dispenser wouldn’t open. Apparently, there was no fix for this other than getting a new dispenser (at a cost of about $140). No one apparently can repair anything anymore; they can just “replace components.” We replaced it twice. The next time it went, we bought a Kitchen Aid, then decided it was so ugly we installed it at work and got a Bosch. The interior of our model was designed by a moron, but it’s only had one problem, so we will keep it until it dies. It’s blessedly quiet.

Another great Health Reform Timeline online

2010-12-23T16:07:00.000-05:00

From Kaiser Family Foundation...this one is a year-by-year breakdown of each provision, some more important than others. See KFF Timeline.

Best of the Best Citizen Portals

2010-12-09T15:40:00.001-05:00

Over the past two years, I've posted links to web addresses to make your voice heard. Here's a recap of the best:

How to contact the White House
How to contact your Senator or Congressman

Here are the very best sources of citizen information on issues of the day:

Summary of the Health Reform Act (with schedule)
Congressional Staff Salaries and Perks
How will the Coming US Debt Crisis Unfold?

Vitamin D and Leukemia progression

2010-11-16T20:11:00.000-05:00

A Mayo Clinic study just reported in the journal Blood that people diagnosed with CLL who had insufficient Vitamin D (less than 25 ng at the time of diagnosis) were more likely to progress and to die than were those with "adequate" levels. Read the press release.

GE is the GM of the future!

2010-11-14T09:54:00.000-05:00

Back in 1978, I had the misfortune to buy an Olds Cutlass, a classy looking car with the classic GM pre-planned burnout at 50K miles. After that, I swore I would never buy another GM car (or American car, for that matter). Hondas became my mainstay and they didn't disappoint with price points and reliability that surpassed my Oldsmobile. In the mid-90's I relented, bought a Chrysler Grand Jeep Cherokee .. Just 50K miles later, when the drive train faultered, I was back to Japan, and my Lexus rx300 is now on it's 115K th mile.

So...now comes GE, the big mother of American major appliances. Our 22 year old GE ovens are still going strong, but our 2-year old GE Profile microwave blew out (magnetron) and GE would not honor the 5-year warranty, because a lead wire had also blown. (Convenient, huh?). This morning, our 8-year old GE Profile refrigerator blew out. We'll pay for repair or replacement, of course, but 8 years is NOT a reasonable length of life for a major appliance! I have resolved NEVER AGAIN to buy a GE appliance. This despite the fact that I own some GE stock. I'm also gradually selling the stock and realizing the substantial loss on the investment. Nothing made by GE is made in the USA anyway... The microwave comes from Malaysia; the refrigerator was made in Mexico.
What's still working in our kitchen? The VERY OLD GE oven; the Kitchen-aid dishwasher (5 years old); the kitchen-aid garbage compactor (22 years old); and the GE profile cooktop (1 year old). Which one would you predict will fail first?

My prediction for 2012 Republican Presidential Ticket

2010-11-03T09:26:00.001-04:00

One of the joys of having this little personal blog is that I can indulge my favorite hobby-- to be able to say "I said that this would happen." This post is to go on record with my prognostication for the republican ticket in 2012. That way I can say, "See?.."
or, more likely, "Well, I don't know diddly about politics, and never said I did." (That latter statement is true.)
Here goes:
Republican Nominee for President, 2012, Mitch Daniels, Governor of Indiana
Republican Nominee for Vice-President, 2012, Marc Rubio, newly elected Senator from Florida.
This prediction should in no way be considered an endorsement of the above. I'm just having fun with my told-you-so hobby. You, dear reader, may have been a recipient of such statements in the past regarding all manner of things, and you know that I live for the times when you say something to me like, "Do you remember way back in 2007, Judy when you told me to sell my house now rather than to wait for the price to improve?" Well, you were right!
Now, if you REALLY want to have fun with me, why don't you counter --in the comments -- with your own predictions. And then we can compare our prescience in September 2012 (God willing).

Federal Employees Health Plan 2011 Premiums

2010-10-16T10:27:00.005-04:00

The US Gov't OPM announced the new rates for 2011 for the FEHB plans. Here is the chart showing 2011 premiums for national plans. For HMOs and other plans available in your area, click on FEHB site page.

For those of you who hate federal workers, you can see what the premium subsidy is for federal employees and retirees. Before you explode and bloviate, however, remember that salary + benefits = total compensation, and in general total federal compensation is not out of line with the private sector. In my view, federal employees are generally more risk averse than private sector workers, or more dedicated to public service, or lucky to have found a safe federal job and aware they couldn't command the same salary in a more competitive system. (Or some combination thereof.) We're no angels, but we aren't total ripoff artists, either.

Vitamin D status & elective orthopedic surgery

2010-10-12T19:48:00.003-04:00

At last, dear reader, the orthopedic surgeons have come around to the realization that cutting into people's bones without testing their Vitamin D status is neanderthal. Here's a report on a speech by a leading orthopedic surgeon at the Hospital for Special Surgery in NYC. Soon, I predict, it will constitute poor quality, if not outright malpractice, for elective procedures such as hip, knee or shoulder surgery to proceed without a vitamin D lab test and appropriate corrective D therapy.
I learned my lesson on D and elective orthopedic surgery the hard way. Maybe a fundamental understanding of the importance of vitamin d status to bone healing will quickly infiltrate the profession. Can't wait for my next follow up visit to find out whether my own orthopedic practice has evolved.

Medicare Premiums for 2011

2010-10-11T14:55:00.006-04:00

Our CBO-Alumni den mother Kathy R sent the attached table around as a first look at what to expect for Medicare premiums in 2011. She took it from a report p ublished September 23 by the National Health Policy Forum. I'm reproducing the table from that report here.

If you're in the "holdharmless" group, it's because you're not new to Medicare in 2011, and your income (modified AGI in 2009) is no more than $85,000. Otherwise, you're in another column. Note the income break points in the table. It makes sense to micro-manage your income if your AGI falls close to a breakpoint.
For example, make $85,001 (if you made only $85,000 in the previous year) and that extra dollar will net you about $58 per month, or about $700 per year, in extra Medicare Part B premium compared with the hold-harmless premium. That's a marginal tax rate of 78,000% on the last dollar (at least I think it is...it's hard for me to calculate high percentages.)

Great summary of the Health Reform Act

2010-09-21T08:35:00.003-04:00

The Kaiser Family Foundation has published a very readable Summary of the Health Reform Act in plain English, except for pesky abbreviations such as FPL (=federal poverty level). Some, possibly critical, details have been left out. For example, if you are going to be eligible for Medicaid, due to low income on your IRS tax form, will the State be able to place you in their managed care program, or will you have to go fee-for-service Medicaid? This is important, because at present most doctors don't accept Medicaid and you'll have trouble finding a provider. Little unimportant details like that.
Otherwise, it's a great place to start.

Embarrassing quotes by those in the public eye

2010-09-15T16:05:00.002-04:00

ProPublica, my favorite investigative journalism website, has started a new site where people (like us) can upload from their smart phones (not like us, cause we don't have one) snippets of speeches or public statements by politicians, business leaders, lobbyists, etc., that are worthy of at least a raised eyebrow.
It's called "Officials say the darndest things!" Check it out, and maybe you, too, can catch a pol in a stupid remark. On the other hand, I say stupid things every three minutes, but I'm genuine. Maybe there's an inverse relationship between stupid statements and genuineness.

Checking up on Charities

2010-08-30T09:45:00.003-04:00

Here are 2 great websites for checking into how your charitable dollars are spent. One of my accounting gurus, who knows about these things, says that these are not perfect, as charities have ways of manipulating these numbers that can't be audited, but it's a start.

Charity Navigator - I like this one best. Has great info.

Better Business Bureau - worth a look.

New Evidence on Vitamin D's role in autoimmune diseases

2010-08-24T15:59:00.004-04:00

This news article in Science Daily about a genomic study done at Oxford University and just published in Genome Research, suggests that Vitamin D deficiency is causal, not just a co-traveller with autoimmune diseases. All the more reason for those of us with autoimmune diseases to take it seriously.

Jane Brody (NY Times) weighs in on Vitamin D

2010-07-27T17:11:00.005-04:00

Jane Brody's article on Vitamin D in the NY Times seems to come a bit late to the table, and it does not seem to reflect the NCI's latest take on the literature linking low Vitamin D to cancer. But, she does have a way of summarizing issues, so it's worth reading. Bottom line: what we knew already. Vitamin D is good for you. You should take at least 1000 to 2000 IU, depending on your stage in life. Most important: get tested.

How to compare hospitals on quality measures

2010-07-15T08:42:00.005-04:00

Here is a great site, from the Commonwealth Fund, Why Not the Best? that allows you to compare hospital scores on a range of quality measures. I just did it for Georgetown University Hospital, a bit late for my surgery that took place earlier this year, but I was gratified to learn that GU has a high quality rating. (Whew!)

Areas of agreement & disagreement on how to reduce federal deficit

2010-07-08T13:33:00.003-04:00

The Committee for a Responsible Federal Budget just published the results of its on-line budget simulation project, where people could vote on which actions they would prefer to see the Federal government take. I'm amazed at how much agreement there is across parties on some things. Seems that it's likely the Social Security retirement age will be raised to 68, if lawmakers follow the will of the pople.

A succinct summary of the Evidence on Vitamin D and Cancer, from the NCI

2010-06-30T10:05:00.003-04:00

This NCI summary of the evidence on the link (or lack of it) between Vitamin D and cancer incidence is an up-to-date for each cancer type. Bottom line: cancer prevention is not the strongest reason for taking Vitamin D, though its role may be clarified in the future.

Why Vitamin D recommendations are so low.

2010-06-28T15:58:00.003-04:00

Here's a great article in the Financial Times about the politics of Vitamin D recommendations. With this issue, there are no bad guys, only policy makers and scientists with different mind-sets about what constitutes good evidence.

To tackle the federal deficit EVERYONE must suffer some.

2010-06-26T09:35:00.005-04:00

Here's an analysis from the Committee for a Responsible Federal Budget which lays out how federal employees have fared over the past few years compared with employees in the private sector. In my view, federal employees should share in the pain to avoid an angry backlash from the American taxpayer in the future.
But, so should everyone else. AARP should take a leadership role here, but I'm not holding my breath.

Vitamin D & Cancer- Could it be just sunlight, and not Vitamin D?

2010-06-22T17:37:00.003-04:00

New studies funded by NCI have checked out whether people with high circulating levels of Vitamin D have lower rates of certain rare cancers, and have come up with zilch. Vitamin D doesn't seem to be related to incidence of those cancers. For example, non-hodgkins lymphoma: not affected by Vitamin D. But, Non-hodgkins lymphoma IS inversely related to sun exposure. So, the authors of that study (available free-click here) speculate that there may be some other effect of sunlight on immune systems, not acting through Vitamin D, which protects against n-h lymphoma. Could such an effect be making Vitamin D look good across a variety of correlational studies? Maybe... we'll have to stay tuned to the research as it emerges.

Closing the Wall Street Tax Loophole: Citizen action needed now

2010-06-14T09:13:00.004-04:00

You may have heard something about how private equity managers are able to shield most of their income from ordinary income taxes, instead paying the 15% capital gains tax. The original bill in the House eliminated that windfall and required them to declare income from investments in which they have no financial stake as ordinary income. Now, the financial reform bill is in Congress, and ALREADY compromises have been made. This morning's Washington Post editorial (strangely and stupidly not available on their web site right now) lays out the latest deal -- only 65% of the income will be taxed as ordinary income, leaving the remaining 35% to capital gains.

These guys (yes, they're mostly guys) make gazillions, and their lobbying efforts are paying off, with stupid arguments about how this will hurt their incentives to take risks. The only risks they take are with their human capital by choosing to work as private equity artists, and I betcha they couldn't make as much money -- even fully taxed -- had they invested their human capital for 15 years to become a brain surgeon!

Now is the time for those of you in swing states (alas, Maryland is full of democrats who will vote for whatever the leadership agrees to) to contact your congressman or senator and demand that these private equity firm managers pay their fair share of taxes. Click here for directions on how to find out who your congressman or senator is, and how to contact her or him.

State-level hospital infection rate comparison available

2010-05-27T15:08:00.004-04:00

Not every state requires hospitals to report their rate of infections, but of those that do, I would choose to live in Washington State or Vermont, and not Maryland! Check the CDC report: First State-Specific Healthcare-Associated Infections Report (scroll down to page 10).

Make your own federal budget choices with this new on-line tool.

2010-05-19T13:48:00.004-04:00

The Committee for a Responsible Federal Budget, a group of gurus who fret about our future (don't we all these days?) has just published a great little tool/game you can use to look at how various spending and tax changes would affect our ability to reach a "sustainable" budget by the year 2020. Try the Budget Simulator.
My favorite among the choices is to increase the gas tax by 10 cents, but I would do a lot more than that! I would vary the gas tax inversely with the oil price to maintain an at-the-pump price of $3.50 (regular), rising gradually to $4.00 per gallon over the next 5 years. That would send the signal that the market needs for manufacturers to invest in energy-saving car models, and for consumers to favor conservation. A double win! Our dependence on foreign fuel would gradually stabilize itself, and some tax revenue would help with the deficit. (We could give some of it back to the working poor by exempting the first $10K of income from social security tax.) My wise environmental activist lawyer friend Ben says this approach would be dead on arrival in the Congress. I'm going to start my own oil-can party, or maybe I'll call it the "Can Oil"Party.

The best time to take vitamin D each day is...

2010-05-09T21:07:00.003-04:00

with your largest meal. Read about it here, from Cleveland Clinic.

Congressional salaries, perks and earmarks available on-line

2010-05-03T12:48:00.003-04:00

Legistorm has all sorts of information on the financial affairs of Congress members and their staffs. You can check out your own Congress person's gifts, travel, salary, and earmarks. This will just make you angrier, regardless of party, so I've filed this under the label "Citizen Portals" (see left), and you can always come back to it when you're feeling in need of a righteous citizen fix.

Vitamin D supplements and breast cancer risk

2010-05-02T12:49:00.002-04:00

Here is information on a new study in American Journal of Clinical Nutrition that suggests (but does not prove) that vitamin d supplements may protect against breast cancer. Click here for news release.

Schedule for changes in the Medicare Part D benefit

2010-04-26T09:11:00.002-04:00

If you want to know how your (or your loved-one's) Medicare Part D benefit will change over the next 10 years as a result of the health reform legislation, see this excellent and short summary from KFF: Key Changes to the Medicare Part D Coverage Gap. What the summary sheet doesn't tell you is what the changes mean for Part D premiums and government spending ... (up up up, of course). Still, if the benefit is out there for everyone else, we'd be stupid not to take our share, right?

How will the coming US debt crisis unfold?

2010-04-24T20:19:00.003-04:00

Here is an interesting report from the Committee for a Responsible Federal Budget outlining several scenarios for how a debt crisis will occur if we don't do something to manage our fiscal deficits in the near future. It's worth reading to try to figure out what kinds of personal wealth management strategies would give you the best chance of riding out the crisis without losing everything (or almost everything.)

Health Care Reform Timetable

2010-03-26T20:32:00.006-04:00

Here's a good summary, from the Kaiser Family Foundation, of what will happen when, as health care reform ramps up over the next few years. See Health Care Reform Timetable.

Hypocritical congress manipulates CBO esimtates.

2010-03-20T18:30:00.006-04:00

An old theory states that regulated industries ultimately "capture" the relgulators and are able to mold the rules to their own advantage. Too bad the theory always seems to work in practice. Now we're seeing it in the manipulation of the CBO scoring process by the "regulated" Congress. Keith Hennessey posted an example of how the House has crafted a Medicaid provision in the reconciliation bill that requires states to pay doctors the same as Medicare pays them, and HAVE THE FEDERAL GOVERNMENT PICK UP THE TAB, without being charged with a $52 billion ten-year cost that CBO estimated for that provision in the original House Bill. The reconciliation bill limits the years in which those increased fees would apply to only two --- 2013 and 2014 -- which brings the cost down to only $8 billion over ten years.

Of course, everyone knows that once those increases go into effect, Congress will never let the fees go back to the old rules. Look what's happened to the physician fee reductions passed in 1997 for Medicare. Each year Congress passes an over-ride, and the reductions are "delayed" for another year. That's what will happen here. So, the health reform bill will effectively federalize Medicaid and add it to the Medicare fee-for-service system (the system that "works so well"). State leaders will love it. Less payout for Medicaid. Doctors will like it, and more of them will participate in Medicaid, which is good for poor people, and by extension the rest of us. Let's face it, though...our deficit hole will just grow and grow and grow.

CBO has no choice but to score the bill this way. It has to assume the law will operate as it says in the bill it's scoring at the time, not as it will play out in reality. This manipulation of legislative language by Congress has improved over time, so at this point the "CBO score" is largely a political football, with the majority using it to hide major new cost-raising changes.

This is just one of dozens of little "surprises" lurking in the bill -- which I admit I still have not read in full and probably never will. What I'm learning is from newspapers and internet. Keith Hennessey's blog is a jewel . I may not agree with him on priorities, but he's an excellent analyst of policy and politics. And he's not lazy. He actually read the reconcilation bill.

"But, Medicare works so well for me..."

2010-03-17T11:59:00.004-04:00

That quote comes from one of my most devoted readers, whose name will go unmentioned. In my never-ending effort to convince him/her that it only works well until it doesn't work, for example, when one cannot find an endocrinologist who will accept a new Medicare patient, I am attaching an interesting article about a new trend among cardiologists -- charging an annual access fee to Medicare patients. This appears to be legal if carefully crafted, and I for one applaud it, provided that I will be able to afford it when my own internist decides it's time to do that same. My doc is worth it, because he does old-style actual communicating-type medicine, and I'd gladly pay extra for those phone calls and email access, etc. But, please, not too much extra $$, buddy, okay? Here's the article from the KFF Website, "As Medicare Pay Shrinks, Some Doctors..."

Vitamin D prevents Influenza A in Children-randomized trial results

2010-03-13T10:16:00.004-05:00

The results of a double blind randomized trial, just published in the American Journal of Clinical Nutrition, is the first definitive evidence that vitamin D3 supplementation actually reduces the incidence of influenza A viruses in children. (H1N1 is influenza A, as is H5N1.) Especially so in kids with asthma.
Check out the abstract in the AJCN website, "Vitamin D".

What the Senate health reform bill would do for women...but not for men

2010-03-10T08:41:00.004-05:00

It's been a long time since I've posted on anything, especially on health reform, because I've been so conflicted. I want to see universal health coverage, and I want to see a regulated health exchange. To me, the Republicans' proposals are insipid because they ignore the realities of the individual insurance market. In short, insurance companies can't offer insurance to all with community rating in the individual and small business markets so long as health insurance is not mandatory, or at least difficult to escape without penalty. So, I want to see reform, and I care about it a lot for my family and friends.
But, those Democrats! Here's a perfect example of the problem. My own Senator Mikulski, ultra-liberal from Maryland, introduced with much emotion (and a speech laden with either stupid inaccuracies or outright lies -- I think the former) a bill that would cover annual preventive visits to doctors for all women for free. Here is Mikulski's own summary of her amendment. The Amendment passed with 61 votes and is part of the final Senate bill.
CBO estimated that it would add about a billion to costs over 10 years. But that's the cost of only about 5 years of actual coverage, since the law wouldn't go into effect until 4 years down the line.
What galls me is the over-reach of the liberals in both the Senate and House, not to mention the recent White House sweeteners, to mandate a rich set of benefits, when what people really need is to be covered when they are sick and scared.
What also galls me in particular about Mikulski is her discrimination against men. And I'm not even one.
I don't trust the Republicans when they say that they want to "just start over", but I can't trust the Democrats not to lard up a bill with new spending.
Bottom line: I hope it passes. Then I hope that the bill will be amended to take out all the stupid stuff, and add to taxes to pay for it. These hopes are also stupid, I know. That's why I haven't been blogging recently.

Don't give to charities through credit cards!

2010-01-18T19:51:00.003-05:00

Friend George is at it again, educating me about the ways of the world. It hadn't occurred to me that giving to Haiti relief, or any other charity for that matter, through my credit card means less for the relief agency and more for the card company and banks. Here's a NY Times article documenting the practice, and reporting that "some" card fees have been waived for Haiti relief.
Why not stay away from giving through credit cards altogether? I'm afraid I was lazy and ignorant this past holiday season and used credit cards to give to some of my favorite charities online. Now I'm reformed. It's direct checks from here on in, with my own postage attached. That has the added bonus of helping the struggling but vastly improved newly privatized US Postal Service stay solvent. (No, I'm not being sarcastic. Have you checked out how hard the USPS is trying these days? There's nothing like competition.)

Wellness Discounts in Health Reform a real problem

2010-01-11T11:01:00.003-05:00

Having already admitted that I cannot read the 4000+ total pages of legislative language in the two final bills (House and Senate) without giving up all other aspects of my life, I'm depending on secondary sources to uncover aspects of one or the other bill that are problematical. Here is what Kaiser Family Foundation says about one provision that sounds discriminatory against those with "lifestyle" issues. This affects people with employer based health insurance. Read KFF News on Wellness Program.

A good link to comparison of House & Senate Health Reform bills

2009-12-27T10:47:00.007-05:00

Here's a good Q&A analysis of differences between the House and Senate bills as passed. Easy To read, from Kaiser Family Foundation.

Medco, Federal Employees Health Plan, and Vitamin D

2009-12-06T15:55:00.005-05:00

Here's a great little piece of "evidence based medicine" courtesy of my Federal employee health plan (GEHA) and Medco, its designated pharmacy benefits manager. Just received in the mail a notice that Medco will not pay for any vitamins, even those available only by prescription. That includes my Vitamin D, which I am directed to take at doses of 50,000 IU every two weeks for the rest of my life. Without it, I don't seem to be able to keep my Vitamin D levels in the territory of normal. Why that is nobody knows, but my family has witnessed the rapid improvement in my post-hip-replacement pain (after two years of getting weaker and weaker post surgery) following the initiation of an anti-Rickets therapy of high-dose Vitamin D. So, in its wisdom, GEHA/MEDCO has said that Vitamins are out as covered drugs.
Now, Rx Vitamin D isn't very expensive. I can buy 12 capsules (3 month supply) at Costco for about $15. So, forcing me to pay for it isn't going to make any difference in my adherence to the therapy. But, it's a perfect example of how little subtletly there is in insurance coverage. Here's one medical technology (vitamin d) that's both cheap and effective (see my previous Vitamin D post for links to the strong evidence that keeps emerging. Needless to say, the blunt instrument that is coverage policy discourages its use.

Some early analysis of the Senate "Reid" Bill

2009-11-22T16:08:00.003-05:00

Here is a great analysis of the Senate Bill by Keith Hennessey, a conservative, I think, but nevertheless, we should know what's in the bill, and his blog is accurate, though opinions are slanted. So I'm putting it up here, because I am just out of gas when it comes to analyzing the details of another 2000 page tome!
AND what's worse, these bills HAVE NO WORKABLE TABLE OF CONTENTS! Yes, they have a list of provisions, but they don't tell you the page. That's just a little bit of Congressional humor. "We want to tell you how to run an industry, but we can't adopt technology modern enough to create a table of contents for legislative proposals."

Why the House Health Care Reform bill is fatally flawed

2009-11-06T08:01:00.004-05:00

Confession: I still haven't read beyond the first 225 pages of the House bill. I got that far because I wanted to understand the structure of the Health Insurance Exchange (HIE), especially how the public option (PO) would work. In a previous post, I concluded it was good enough, but worrisome in the long run .
But, today Martin Feldstein, a noted Harvard economist (not my favorite, but way smarter than I) has an op-ed piece in the Washington Post (Obamacare's Nasty Surprise) that lays out clearly why the House bill will not work as presently structured.
The basic flaw is that the law requires health plans to enroll all comers, regardless of health risk, but it doesn't provide carrots/sticks to individuals or businesses that are strong enough to induce the young and healthy to enroll. So, premiums will go up, kicking off a cycle of adverse selection into the HIE by the sick or high risk and opt out by the healthy.
There are ways to fix this problem, but apparently they are not in the bill, or surely Feldstein would have mentioned them.
One solution would be to charge anyone who does not sign up (or have qualified coverage) within the first year of the program a "premium penalty" for the rest of their lives. That's what happens with Medicare Part B, and why even the healthiest 65 year old is willing to pay right away. For every year of delay after you reach 65, Medicare adds 10% to the Part B premium for the rest of your life.
Another solution would be to increase income tax penalties.
A third solution would be to increase subsidies.
I like first idea, though, because instead of being seen as a "tax," the penalty would be seen as just retribution for a young person trying to game the system by delaying enrollment until he/she encounters the inevitable need for health care.
BUT... so far as I know, this solution isn't in current health reform proposals. Why not? That's where Feldstein sees the invisible hand of the single-payer lobby. As the cost of insurance goes up and up, and as fewer and fewer people are insured, a single-payer system will be the only alternative.
Design a HIE market to fail and you'll end up with a single-payer system. So many of my dear friends, family members, and readers want this outcome that I am in despair. Why do we think that a government monopoly is any better than a phone company monopoly in the way it will treat us? Supporting a move toward public monopoly of payment for health care is to say we want health care to be run the way that public education is currently run. Good teachers underpaid; average income children underserved; rich children opting out.
That's the best I can do by way of diatribe right now.
Have a great day.

Two Doses of H1N1 vaccine better for children

2009-11-03T08:32:00.003-05:00

Here are the findings, in CIDRAP's News of yesterday. Still, if you can get just 1 dose for your child it's worth it, as the first dose confers some immunity and will probably make the flu less virulent in him/her. (This from a non-doc, mind you.)

How health reform will gradually evolve to single payer system

2009-10-31T09:43:00.004-04:00

Leaving aside the pros and cons of a single-payer system (SPS), I'm beginning to believe that a SPS would be an inevitable consequence of any health reform proposal that contained a public option (PO), even one as benign as the current version of the House bill. (See my previous post on good points of that bill.)
I'm basing the scenario on my long-time experience as an enrollee in a prototype health insurance exchange (HIE), namely the Federal Employees' Health Benefits Program (FEHB). FEHB has about 8 million enrollees, including current federal employees, their families, and retirees.
First off, I need to explain that the FEHB program is a regulated marketplace with open season at the end of every year, during which enrollees can choose among roughly 10 plans, depending on their place residence. Government subsidizes about 75% of the arverage plan's premiums (as do many employers.) Less subsidy goes to enrollees in richer plans. None of the plans are POs. All are private, but some are not-for-profit.
Here's what has happened to me over the 30 years of enrollment. When I was young and feeling good, I enrolled in a plan with relatively low premiums (never the lowest, cause I'm risk averse). As I got older and more needy, I opted for a richer plan, paying more in premiums but using health care more. Apparently, so did lots of other aging enrollees, because the costs of that plan began to skyrocket. And, that plan began to add draconian control features to the management of its benefit. And more and more doctors opted out of that plan's network. Finally, the costs got so high and my mistrust of the plan grew so much(especially in the past year) that I chose a low cost plan and paid more for visits and drugs than before. Overall, I might have paid more for health care (counting premiums and out-of-pocket) but at open season last December I was willing to take the gamble. This year, though, I'm torn, because the lower cost plan leaves me exposed to higher drug costs and less generous coverage of some services and devices that I might need in the coming year, given my decrepit state. So, right now I'm weighing a choice between two plans whose premiums vary by a ratio of more than 2 to 1. My choice is based on what I know now about my current state of health, which none of the plans can take into account in deciding to enroll me. That's the beauty of "open season" and "guaranteed issue."
Now fast-forward to a grand health insurance exchange, as envisioned in the House bill. That plan would also have a regulated market place with private insurers offering benefits that can differ within a defined range specified in the legislation. When I say "benefits", I mean things like the deductible, coinsurance or copayments, catastrophic limits on out-of-pocket expenses, networks of physicians, hospitals and other providers, care mangement techniques like prior authorization for expensive procedures, etc. An example of a limit on benefit variation is the requirement in the current House bill that every plan cover well child care visits with no copayment or coinsurance. (i.e., free well child care--costs would be covered through the premium assessed on all enrollees.)
Without a PO, the marketplace would behave similar to the FEHB program. People would check out premiums, networks, deductibles, etc., and would choose the best plan for them. Over time, there would be sorting of enrollees, and the costs of different plans might diverge. If the House bill became law, the young&healthy would enroll in the cheapest plan possible, while the old&sick would enroll in richer plans. This process would be mitigated to some extent because in the new marketplace, plans could vary premiums by age by a ratio of 2:1. (That's not true with FEHB, where we all pay the same premium.) So, in the House bill, the young&healthy would pay less for richer coverage and at least some might be induced to buy richer coverage.
Now, enter the Public Option (PO). Under the House bill, the amount that PO pays doctors and hospitals can never be greater than the average payment rates under private plans in the marketplace. Most likely the PO administrator will "negotiate" with doctors as follows: "We're paying Medicare rates. If you want to participate, fine. If not, hasta la vista." Lots of doctors might opt out of the public option, because right now Medicare rates are about 30% below private insurance rates. Hospitals may be stuck with the Medicare rates, though, because it could be very difficult for the major or only hospital in a community to thumb its nose at a public insurer. (I just don't know what hospitals will do.)
In any case, the PO premium is likely to be lower on average than those of private plans. Who will choose the more limited PO, with its more limited, perhaps less "elite" physician network? The young&healthy, of course. That will make it easier for the PO to pay for itself with lower premiums overall. Lots of young&healthies choosing the PO would mean that their premiums would be low, and the oldster's premiums would also be held down (by the 2:1 rule). Meanwhile, the private plans will attract us old&sicksters, and their premiums will be driven up. Eventually, some of the old&sicksters will give up on the "elite" docs and will enroll in the PO. This yin and yang will continue over time until, gradually, the PO (which still has the cost advantage due to payment of hospitals on Medicare rates) has become the behemoth. With lower and lower market share, private insurers will fail, merge, exit the market, etc., and real competition will be gone.
If you've read this far, I must tell you that I'm not completely sure of my prognostication. Competition is dynamic, innovation is inherent in markets such as this. I could be all wrong. That's why I'm not wringing my hands at the public option currently in the House bill. The uncertainty is great enough for me to say, okay, let's pass a law that makes health insurance affordable and get on with it. But, I'm mindful that the great long-term danger is the decline of the health care system into a single-payer system. Perhaps in the future I'll post something on why I'm so worried about single-payer system.

My first take on House Health Reform Bill

2009-10-30T13:58:00.007-04:00

Ok, okay, so I've gotten through only the first 225 pages of the bill. (Read the 1,990-pages of the House "Affordable Care for America Act" yourself, if you think I should be faster!) I like this bill better than the Senate Finance concoction, but some things are worrisome.

The Good:

HIE Membership: All firms would eventually be allowed to enroll their employees through the health insurance exchange (HIE), thus encouraging over time a big pool of enrollees in this new system of competitive health care plans.
HIE Administration The HIE would be national in scope (though States may opt out), so the pool of enrollees would be large (very good) and the administrative expertise to set up and regulate the exchange would be centralized. (That's efficient.)
Premium Cost Structure within HIE: The range of premiums would be limited to a ratio of 2 to 1, so older people (the 50=64 crowd) wouldn't have to pay exhorbitant premiums.
The Public Option - participation: The public option (PO) will not require physicians to participate as a condition for them to participate in Medicare. That is, physician participation in the PO is largely unlinked from participation in Medicare. (This is very important in keeping the whole system from slipping into a single-payer Medicare program for all.
PO Payment rates to physicians: Physician payment rates under the PO would be negotiated but couldn't be more than the average rates paid by the private plans in the exchange. (Also can't be less Medicare rates.) So, if the PO administrator wanted to use the Medicare rates as the basis for participation, that would discourage doctors from participating, and the PO would become a bare bones plan in the sense that the availability of doctors to PO enrollees would be somewhat limited. (This would probably vary by area of the country.) You get what you pay for. Maybe quality for those people who choose the PO won't suffer. Who knows? What's quality in health care anyway? (If you think you know, you're wrong..Nobody knows, least of all myself.)
Participation of "Other Providers" in PO: The PO administrator would "negotiate" a rate at least as high as Medicare's DRG rates, and perhaps higher. The only practical "negotiation" on the part of the PO is to specify a multiple (say, 1.05) of the Medicare DRG rate. That higher-than-Medicare rate would mollify hospitals and other non-physician providers in the short run, and they would probably choose to participate, given the high fixed costs of hospital operation (volume is the name of the game for hospitals.) Now, this is good news, bad news, in my view, because other insurers may not have the market clout to demand that hospitals pay on a DRG basis, even one that's higher than the Medicare DRG rate. But, maybe insurers SHOULD play hardball with hospitals, and it is possible that this would encourage hospitals to take the lead in developing integrated systems of care (with doctors) that provide their own insurance offerings to people in their regions. That way, hospitals and physicians could share in cost-savings from delivering care more effectively and efficiently. In any case, hospitals' and other providers' ability to refuse to participate in the public option is an important safeguard for competition.

Worrisome things (other than cost, which I think we should pay for through a dedicated gasoline tax that brings prices at the pump to $4.00,..but that's another story and is so far beyond the fringe that I won't continue with it) will come in my next post, if I can ever slog through more pages of this bill.

Back to the Summers Blame Game

2009-10-21T17:38:00.003-04:00

Frontline had a great program on our gal Brooksley Born, sometime head of the CFTC who tried to regulate the credit default swap market and was blown down by chief bloviator Larry Summers et al. and Sen. Phil Gramm (he of the late night Christmas 2000 law to "modernize" the CDS market by rendering it beyond the purview of regulation). It's on-line at PBS: The Warning. (Read about Brooksley at links provided in my May 26 post about her.)
It got me back in touch with my inner raging populist once again to ask the question: What the heck are Congress/White House doing to reform the financial markets? Brooksley answered this question in her Frontline interview: NADA!
What needs to be reformed? Two things, in my view:

The laws that require insurers, pension funds and mutual funds to rely on those heinous ratings agencies (Moody's, S&P, Fitch) for directing their investments. SEC anointed those three as the chosen few, even though they (ratings agencies) were paid by the issuers of the securities for the ratings that would determine how much interest the issuers would have to pay investors. (COI!) Even the FED got into the game, telling the banks it regulated that it could treat AAA securities as good as cash.
The easy money policy that led to the big pot of cash for investments in these doggy instruments.

Have you heard anything lately about either of these problems being fixed by Congress? by the FED? By Larry Summers? No? How shocking!

New entries in the growing Vitamin D evidence base.

2009-10-18T17:57:00.004-04:00

Friends have been alerting me to new findings on Vitamin D. Stunning evidence on its importance to human health continues to mount monthly.
If you're young and athletic, take a look at the Sept 29 New York Times blog post on Vitamin D and athletic performance. (Thanks, Lisa T.) Take the time to read the comments readers have left on the post; they crystallize the issues that believers and doubters are debating.
From Clare G. comes word of a study of high-dose Vitamin D & physical therapy in preventing falls and hospitalizations in elderly people after hip fractures. This is a clinical trial reported at the annual meeting of the American Society for Bone and Mineral Research. Good summary is in Medscape.com (You'll have to register to see the article, but it's a good site for medical literature, so why not?) The gist is this: Patients taking 2000 IU of vitamin D had a 25% reduction in falls and a 39% reduction in hospital readmissions compared with those taking 800 IU per day. That included a whopping 90% reduction in infections bad enough for hospitalization in the higher-dose Vitamin D group. What's good for the elderly is good for me! (Of course, in a few months, I will be one of the elderly, so that's a tautology.)
Finally, take a look at the following YouTube videos of a Vitamin D conference at the University of California San Diego (Feb 09):
Robert Heaney, M.D., (Creighton University) - Great talk on how much Vitamin D is enough? How much is too much? He and the data will convince you that 2000 IU is a reasonable amount to be taking and it won't hurt you.
Cedric Garland, Ph.D., (UCSD)- an epidemiologist who reviews evidence on Vitamin D and cancer prevention (and treatment). Gets pretty technical, but if you slog through it (as I did )you'll at least get the rough sense (as I did ) that the latest (stunning!) findings regarding breast, prostate, and other cancers make sense scientifically.
Other presentations - including Vitamin D and cardiovascular disease, diabetes, and autoimmune disease are also available at the Conference home page (see right hand panel for clickable presentations).

What the Obama administration is doing wrong on the banks

2009-10-18T15:28:00.003-04:00

Here's a great 10-minute interview in the New Yorker's Blog page of Joseph Stiglitz, a liberal economist, who is critical of the Obama Administration's handling of the economic crisis, particularly bank reform. What I like most about what Stiglitz (a Nobel prize winner) has to say is his defense of market mechanisms, properly regulated. This isn't about health reform, but if you keep it in the back of your mind as you listen to Stiglitz, you'll appreciate why I'm such a proponent of a regulated competitive market place for health insurance. Public plan could be in there, provided it doesn't use the leverage of the Medicare program to exact price concessions from hospitals and doctors that private insurers cannot.

Medicare, Medicaid, and Mayo Clinic

2009-10-13T15:49:00.005-04:00

Today's Washington Post has an article about Mayo Clinic's decisions to opt out of Medicare for primary care in its Scottsdale Arizona campus and to refuse to accept Medicaid patients from certain mid-western states. Here's a link to an Oct. 9 news article in the Arizona Republic covering the Medicare decision .
Doctors all over the country refuse to accept Medicaid because of states' tendencies to pay even less for physician services than does Medicare. So, Mayo's opting out of some states is no big thing, in my view. The miracle is that they do participate in the Medicaid programs of MN, WI, ND and SD.
But, the decision of Mayo Scottsdale to refuse Medicare for primary care needs more consideration. Sounds heartless on its face, but my reading is different.
Here's what Mayo-Scottsdale is probably doing to stay within the confines of the law. It must be designating certain of its doctors (those manning one of its family practice facilities) as "opt-out" physicians. That Medicare jargon means that those doctors will not accept Medicare payment for any of their patients, and Mayo will not submit a bill on behalf of the patient for any of the services rendered by those doctors to Medicare patients. The patient is on the hook for the entire charge, and Medicare won't pay a penny for the services provided by an opt-out physician. Hear me? The patient cannot get a penny from Medicare when treated by an opt-out physician. Mayo is charging the Medicare patient who wishes to have a Mayo primary care physician an annual access fee of $250, plus fees for visits that are higher than the Medicare fee schedule allows.
Once the patient needs to see a specialist of any kind (say a radiologist, an endocrinologist, yada yada), or needs lab work, or special procedures, however, Mayo will bill Medicare on behalf of the patient. And, in that case, by law, Mayo must get no more than about 115% of the fee allowed by Medicare. So, the patient is completely on the hook at Mayo only for the services of the primary care internist.
Now, the unpleasant reality is that most Medicare patients who would pay, say, $1000 each year in excess fees are unlikely to be poor. So, the criticism of Mayo as catering to the elite in its primary care is somewhat valid. (Why do you think they located a new campus in Scottsdale in the first place?) But, --and here I am an expert as a sometime member of the Mayo (Rochester) staff and an occasional patient -- what the patient gets for that extra money is the kind of attention that most of us see only in Norman Rockwell paintings. First off, the Mayo community medicine doctor lets you talk and talk. You NEVER feel rushed. This is really true! He or she takes a thorough history. The visit almost always takes over a half-hour. (Time your next routine visit to your internist to compare.) You feel as if the doctor hears you. It's wonderful. Need a referral to a specialist? You get it, and you get it fast. Need lab work? It's done there, and the results come back quick. You're not left waiting for a month as you schedule that consult across town.
Does this make Mayo infallible? I haven't found it so. Those doctors have missed things in my case. Still, I never feel angry because I chalk it up to the inevitable imperfection of doctors in the face of mind-numbing variability and complexity of human disease. I've never chalked it up to the doctor not caring. Out here in the real world, though, I often do chalk it up to that.
Now, it's no secret that Medicare underpays for primary care services relative to specialist care. See Kaiser Family Foundation's background piece on the shortage of primary care docs. So, rather than start rushing patients through the system to meet its costs, Mayo has taken a stand against Medicare's crazy fee-for-service system. Lower income Medicare patients, or those who take umbrage, will have to see other docs for their primary care; they can still be referred by those doctors for specialty care at Mayo.
This is a signal to the Medicare fee-for-service system. You just don't work!

How to bend the health care cost curve- some good sources of info

2009-10-12T09:57:00.004-04:00

The New England Journal of Medicine has three good articles about health reform this week. They are all free to non-subscribers and are easy to read and understand. Obviously, they're intended for doctors, but they explore the possibilities for bringing health care costs under control. The first one is a roundtable hosted by Atul Gawande, the now famous surgeon who writes in the New Yorker on health issues. David Cutler's article, which argues that cost moderation going to happen regardless of reform, is really interesting. But, if you want to know the politics of the Baucus bill, from a polished health journalist, read John Iglehart's summary of what's happening.

New CDC guidelines for Docs for H1N1 treatment

2009-10-06T09:10:00.001-04:00

I'm following the University of Minnesota's CIDRAP website for interesting news about H1N1. Yesterday's postings were very useful! They put to rest a lot of rumors about vaccine safety etc. One entry alerted me to new CDC guidelines just put out for doctors to follow in diagnosing and treating suspected H1N1 cases. CDC says these are NOT for laymen, but they're just not that hard for a layman to understand! And saying that assumes that every doctor in the world is going to be right up to speed on the latest. So, here they are for my fellow laymen for easy reference: CDC H1N1 Guidelines

The "Premium Bands" in health reform debate

2009-09-30T20:50:00.012-04:00

Last Friday, the Baucus (Senate Finance) Committee debated the large variation in premiums that health plans participating in the health insurance exchanges could charge based on age. (Thanks to Michael G who alerted me to this.) The bill currently allows the health plan's premium to vary by a ratio of 4 to 1 between the youngest and the oldest. That's a reduction from the 5 to 1 in the original proposal. (So, for example, if a 25-year old is charged $2000 per year, the 64-year-old would be charged $8000 in premium.) I've already argued (in my Sept 15 post) that this high ratio is not good.
On Friday, Sen. Kerry introduced an amendment to reduce the maximum ratio to 2-1. Both Kerry and Wyden were eloquent about the issue. (If you're a health policy junky, you can hear the entire hearing on C-span, Friday 28).
Kerry ultimately withdrew his amendment, but he promised that it would come up later in the final debate on the Senate Floor. We should watch this issue. The fairness of health reform rests on three things: the premium subsidies for lower-income people; the size of the penalty for those who refuse to buy insurance; and the extent of age-rating variation allowed. So, this is an important aspect of any plan that's put forward.

Who says Canada's health system is better?

2009-09-30T17:12:00.008-04:00

My friend George S, for one. Of course, the last time George lived in Canada he was young-- I won't say how many years ago that was, but twern't yesterday. George believes in a single-payer system, and though he is otherwise the brightest and wisest, I can't seem to get through to him on this issue. He just loves the health care he received from the province of Ontario. T.R. Reid, who just authored a book on health care systems around the world, seems to agree with George. He must be young, too! To see & hear to his lecture on how bad US health care is and how good Canada is, click here.
Now comes an article in the LA Times ("In Canada...") about the problems that Canadians have in getting access to care in Canada. At issue is whether Canadian physicians can offer care outside the province-run health care system. The article gives examples of long wait times for such things as hip replacements (ooh, that one hits too close to home) or MRIs in British Columbia.
True to my research roots, I checked this out with friend Maria, who lives in BC and knows a lot about the health care system there. "Is this for real?" I asked via email? Here's her answer:

"There are significant waits here for elective surgery and the situation with imaging is really quite bad. Interestingly, there is a private system for MRI's, so if you don't want to wait up to a year for one, you can legally get one privately (at about $800). Some people also opt for private cataract surgeries and this is done somehow legally. The current government in BC is "Liberal" but is curbing services in the face of budget deficits.

As a true Canadian, Maria remains optimistic and trusting:

"Efforts are being made to reduce these wait times and despite the system's shortcomings, it is in my humble opinion a better one than exists in the US."

So, next time George wants to argue with me about single payer, I'm prepared with facts that will matter to him now that he's no longer one of those "young invincibles."

Baucus Bill Changes as of Sept 22- new summary

2009-09-24T11:13:00.004-04:00

Here's a link to the summary of the Revised Chairman's Mark for Senator Baucus' Finance Committee Bill. Over 500 amendments have been submitted. Those are beyond me to keep up with, but reading the Summary of how Baucus has changed things so far should help us keep track of where we are on the "affordability" issue. And, we should be explaining to people how very de-stabilizing will be the very big range of variation in premiums (by age and region) allowed in this bill. It simply won't work if older (55-64) people can't afford health insurance. The young NEED to subsidize the older to some extent. Furthermore, if Wyden's idea that the health exchanges should gradually replace employer sponsored health insurance, then American industry will be more competitive & the young would have more job opportunities and better wages. Without a reduction in the premium ratios, the whole scheme won't work, and the benefits to the young in the form of jobs won't come about either!

Cash for Clunkers cost us (taxpayers) $2000/car

2009-09-22T10:09:00.005-04:00

Here's a great AND READABLE article in an electronic economics journal--The Economist's Voice--about the net costs to our society of the cash-for-clunkers program. By two University of Delaware economists. Net, it cost us about $1 billion extra...small change? One quote from this article is worth the whole thing: "Concentrated benefits create vocal advocates while diffused costs produce silent apathetic opponents."

Good news on H1N1 Vaccine Front-No adjuvant

2009-09-21T17:02:00.002-04:00

I've been wondering what the fast-track approval of H1N1 vaccines would mean for vaccine safety. Today, Andrew Pollack's article in the NY Times, "Benefit and Doubt in Vaccine Addititve," assured me that USA isn't planning to approve any vaccines with adjuvants this go-round. That means the safety concerns associated with fast-tracking the approval aren't an issue. Only question now is whether the vaccine will arrive before the flu itself does.

An amendment to Baucus bill worth considering..

2009-09-17T20:11:00.003-04:00

Sen. Ron Wyden (D-Oregon) wrote a great piece in today's NY Times arguing for a change in the Baucus bill. It would go a long way toward making health insurance work for everyone, and putting us all on an equal footing when it comes to having access to coverage.
The Baucus bill is pretty good, except for the wide variation in premiums that would be allowed on the basis of age. See my previous post for a description of the problems there. Wyden's amendment wouldn't work if such wide deviations survive in the Baucus bill, because only the young would leave employer plans for the Health Exchange, and companies would find themselves paying more for their own plans. They would soon dump their own plans, leaving older workers to buy on the exchange and pay high premiums while getting only an average subsidy from the employer. (Employer plans do NOT vary benefits by age of worker, so they would not give higher subsidies to older workers trying to buy a plan in the health exchange.

The Baucus Bill isn't that bad.

2009-09-17T08:49:00.006-04:00

Here is the link to the Senate Finance Committee's "Chairman's Mark", released yesterday and supposedly the starting point for the compromise bill that will be acceptable to a wider range of congress.
All in all, I think it is a good framework for reform, except for a couple of things. The most important problem is that it allows private plans to charge very different amounts to different populations of people. If you're, say, 60-65 years old (too young for Medicare and too old to train for a new lucrative career), you'll have to pay a LOT for health care coverage (5 times more than for younger people). Say you're a single person 60 years of age making $50K a year. You'd be excused from the requirement of either having to buy insurance or pay a fine to IRS only if the lowest premium available to you was more than $5000. (You wouldn't be eligible for a tax credit to help defray the cost, because you'd be too rich.)
That's simply too much for most people I know, and because the 60-65 year olds will shoulder the greatest premiums, it basically says fuggedabout relief. You'll just be penalized if you don't buy coverage, and you still won't be able to afford coverage.
Let's get real. We need to provide a fair insurance system for people who can't get it through the workplace. Those same people must have incentives to be frugal about how they use their covered care. A system of COMPETING regulated health plans offering benefits with a standardized value is the best way to change the health care system to be more efficient in the delivery of care. Nothing is ever perfect, but consumers can vote with their feet by changing plans when they find one or the other not meeting their needs.
I started working on health care issues in 1971. Over the years, I would ask physicians, nurses, and other health care professionals with whom I worked on committees and panels to estimate, off the top of their heads, what percent of health care costs is wasted. It varied, but the most frequent response throughout the years was 40%. (20% also was suggested a lot.) And, it didn't get any lower as I got older.
Right now the system isn't organized to capture those savings. As patients, we all know the problems. Duplicative tests, doctors not communicating, incentives to test and prescribe too much, etc., etc. To change things in the culture of medicine, you need to change the organization of medical care. My two years working at the Mayo Clinic in Minnesota in the mid 1990's taught me that medical culture is very important, and that the organization needs to have incentives to make their practitioners change behavior.
Mayo was organized better than any system I've ever seen. They were most efficient in the conduct of individual services (xrays, lab tests, visits, etc), but they provided a very intensive set of services. Mayo is still paid largely on a fee-for-service basis. Imagine the innovation that would be forthcoming if the majority of its patients signed up as HMO members in the "Mayo Clinic HMO." Mayo would be a leader in deciding if and when services were justified on medical grounds (let alone costs). Under a competing system, Mayo might have incentives to build its HMO into an offering for most people in southern Minnesota.
So, we need the Baucus framework, with some tweaks, but we need to have the young subsidize the old (young-old, non-Medicare). The young will be old someday too. Keeping the young in the pool with the old will keep premiums more affordable to those most vulnerable. The 50+ crowd who start succumbing to chronic and debilitating disease.
If you agree or not, you can find out how to contact your congressman or senator in my recent post, How to Contact Your Congressman or Senator. They need to hear from you. Here's a good news article that shows how important your voice can be on this particular issue.

Does washing hands help stave off flu?

2009-09-16T17:16:00.003-04:00

Here's an interesting Newsweek article that suggests hand washing isn't likely to be effective in preventing the spread of flu. Won't hurt, experts say, but it could make people -- especially kids -- complacent, when it's transmitted through the air. That Elmo trick of sneezing and coughing into your elbow seems to be a better tactic.

Who are the Uninsured?

2009-09-15T15:22:00.007-04:00

The Institute of Medicine published America's Uninsured Crisis early this year with the most informative table I've seen on just who are the people who are uninusred in the USA. Table has demographic and income distribution data. I didn't know, for example, that immigrants (legal + illegal) make up 20% of the uninsured population. No breakdown between them. Also, the number of illegal immigrants may be too low, because the data are based on a sample, and illegal immigrants may be less inclined to respond.
Two ways to look at this: Way 1: OMG, we could end up paying a lot to insure illegal immigrants (and encourage more to come) if we're not careful. Way 2: OMG, health reform won't help a substantial portion of our hardest working and most vulnerable residents. I'm a 2nd way kind of gal, but I can see the arguments of the 1st way folks.

The Senate Finance Committee's Health Reform Plan

2009-09-15T09:26:00.012-04:00

This is the "Baucus Committee", which is generally more conservative than the Senate HELP Committee (Kennedy, Dodd & Harkin). The SFC's bill hasn't been drafted fully, but last week Sen. Baucus released an 18-page summary of its provisions so far. I relented from my new "kill-no-trees...create-no-paper-waste" policy and actually printed a copy and then actually read the thing.
Here are some things to worry about in this bill (and why):

Insurance market reforms - (p2-3) - Although plans would have to refrain from discriminating against pre-existing conditions & must eliminate lifetime limits on coverage, they could vary premiums by age group, up to a ratio of 5-to-1! That's pretty substantial for the 50+ crowd who are likely to need the most care. It's basically saying that each age-group of uninsured will subsidize itself. No transfer from the young to the old. It would not provide real relief on premiums for the older laid-off crowd that can't change careers fast. Oh, and by the way, plans could offer a super-cheap policy for the "young invincibles" who wanted only catastrophic coverage, thereby siphoning off the lowest risk segment of the population from the general market. End result? VERY HIGH PREMIUMS for older uninsured people. Makes the idea of "affordability" laughable for anyone who isn't young and healthy or near-poor (see below).

Benefit options- (p3) - Oops! First I got this wrong. I thought that the summary was saying that Plans could keep 35% of premium collections for their own expenses & profits. What they really meant was that each plan's benefit would have to limit patients' out-of-pocket expenses to 35% of total costs (on average across enrollees). That's much better. So, I'm not worried about the plan options they're talking about.

Health Insurance Exchanges - these would be set up and run by the states, instead of a Federal bureaucracy. Excuse me, but I'm from New Jersey. (Enough said?) In all my years working in Washington near or in the Federal workforce I've never seen the incompetence, waste and corruption that I've followed in my home state. (Well, maybe in my first years as an intern in a dying federal agency.) It's a bad idea in this case not to have the regional markets organized by a central commission. There, instead of 50 state bureaucracies reviewing insurance offerings for their fine print, you'd have just one. Regions would be distinct, but the expertise to regulate the markets would be centralized (like Medicare).

Medicaid - (p. 7-9) This section is unclear, but it appears that people between 100% and 133% of poverty will be able to choose between Medicaid and the Health Insurance Exchange. That's good. And, instead of completely federalizing the funding for that newly eligible group (as in the House bills), States would have to share in the cost. At least I BELIEVE that's what the section says. Read it for yourself. Making States share in the cost of providing care for Medicaid is a good thing, since they actually administer the programs. Of course, Governors hate this because they don't have enough money right now, and how would they come up with new money? The 55/45 split between Washington and States called for in the proposal could be altered so that federal taxpayers pay more, but States should have some skin in the game if Medicaid is going to be covering these people. And giving working people the option to join the exchanges (with subsidies) is a good thing. Who wants to be in Medicaid? Nobody that I know, rich or poor, unless there is no other option.

Subsidies to Low income individuals (p 3-4) - Up to 400% of the poverty line, you'd get a refundable tax credit (i.e., whether or not you owe taxes). According to the Institute of Medicine, that's about 80% of the population of uninsured people. For example, at 400% of poverty, your premium payment would be capped at 13% of your income. For a family of 4, with a household income of $88K, (400% of poverty) that would mean a cap of $11K. Gov't would give tax credit for the rest. At least I think that's how it would work. Read it for yourself and let me know if I've got it wrong. jwagner@bethesda20817.net. Does that sound affordable?

Revenue Provisions (p. 17) - I love the new tax on employers with high-cost health plans. The tax would ultimately be 35% of the plan expenses beyond the threshold. The tax would give employers incentive to reduce their health benefit costs. And I don't like the idea of subsidizing (with my tax dollars) the high-cost plans of the richer companies. On the other hand, the bill would completely eliminate the subsidy that employers get when they give Medicare-eligible retirees drug benefits. That's currently a 26% subsidy for every dollar of benefit. It's what has kept employers from dropping health coverage for Medicare-eligible retirees. Lots of employers might drop coverage for retirees. Is that bad? Medicare drug benefit is still available for all. So, I'm not sure whether it's bad or good. More thinking to come.

Legistorm Gives the Skinny on Congressmen & Staff

2009-09-10T21:05:00.002-04:00

This site, Legistorm, is fabulous for finding out what kind of travel your Congressman, Senator, and his/her staffers are taking at your (taxpayer) expense. Want to know whether your guy/gal is a big "earmarker"? You can find that out too. And, get a peek at financial disclosures, though they're much less informative than the travel expenses. And, staff salaries! That will tell you what working on the Hill will pay for, example, the Chief of Staff for the House Majority Leader. Check it out.
Of course, none of the salaries comes close to that of Michael Kaiser, CEO of the Kennedy Center... over a million a year, according to the Washington Post Magazine last week. That's the last penny KC will ever see from me! Nobody in Washington needs that much money to live the high life. I bet if KC Board told MK he'd be out if he doesn't take a 100% pay cut, he'd cave. He's the "turnaround king" for cultural institutions, and he donated a kidney to his sister. Still, half of his million could fund a lot of struggling young ballet dancers.

Latest on H1N1 status

2009-08-29T08:33:00.004-04:00

College campuses are already sites of mini-epidemics, and a friend's workplace in California has had a rash of cases in the past 3 days. With schools starting, we should expect H1N1 to ramp up fast.
My favorite source of info on H1N1, and up-to-date info on whether and how it's changing, lethality, etc., is CIDRAP at the University of Minnesota. Here's a link to CIDRAP's latest info (as of yesterday-Friday Aug 29). Good news is that the virus hasn't mutated. Bad news is that some young healthy people are getting serious viral pneumonia, that MUST be treated fast. Good news is that resistance to main anti-viral drug (Tamiflu (tm)) is still isolated and rare. But, getting care right away if lower respiratory tract is involved is important!
For a list of signs and symptoms of serious swine flu infection, see my posting of Aug 1, 2009,
Check into my posting of June 26 for information on what you should expect your physician and hospital emergency room to do when you do seek care..

"Public Option" out! "Choice and Competiton" in!

2009-08-17T08:20:00.002-04:00

I hoped it would happen. The Obama Administration has seen the light and is ready to give up on a Medicare-linked public option (the only kind that could give the public plan an unfair advantage in a reformed marketplace). Now, the buzz-words from HHS Secretary Sebelius and Gibbs (WH Press Officer) are "Choice and Competition". I love it!

The problem with the insurance market has NOT been the evil insurance companies. The problem has been a failure of market regulation to guard against the four sources of market failure in health care insurance:

adverse selection bias into health plans -- If health insurance coverage is voluntary, and insurers can't deny coverage, only the old, or sick, or vulnerable will apply.
Cream skimming by health plans -- When insurers CAN deny coverage, or charge different rates to different people, only the healthy will be able to get insurance;
Incentives for over-use by the insured -- (this is called "moral hazard" by economists, a term that I consider to be incredibly stupid because it doesn't help me understand the problem. It's just an economist's way to keep normal people from thinking they know anything.) It's simple: if you don't pay the doctor anything (or very little) for a visit, or a test, or a procedure, etc., you'll have no incentive to restrict utilization or keep the doctor honest when he/she bills the insurer.
The provider is your "agent" in making health care decisions. Well, we pay him/her for that, don't we? Yes, but in this fee-for-service world he/she has an incentive to do more, or at the very least not to conserve resources. So, for example, the doctor may not get any money from ordering an MRI to rule-out something very unlikely but horrible, but he has no incentive NOT to order it, and it will justify a return visit (for which he'll be paid).

If problems 1 and 2 are fixed through regulation -- health insurance must be mandatory for all & health plans cannot discriminate either in coverage or premiums -- and if plans must compete for your business, then most of these problems will dissipate over time. It's the only way to get control over health care costs without leading to a single-payer system. (And I'm against a single-payer system, because Medicare and Medicaid are NO role models for efficiency and effectiveness in health care.)

More on the Pros and Cons of the Public Option

2009-08-16T11:36:00.011-04:00

Richard Thaler (a well-known economist, born in NJ, too!) has a good piece in today's NY Times on the Public Option controversy surrounding health reform: "A Public Option isn't a Curse or a Cure." He says what I said (but I'm not such a well-known economist). He even refers to Victor Fuchs as the "Dean of Health Economists"... did he read my blog post of June 1? (ha ha...don't think so, but I like to brag anyway).
Thaler points out that, given a level playing field, government run enterprises NEVER out-compete private enterprises. Only if the public plan can exact concessions from providers (through legislative means) that private plans can't, will it be successful. Thaler emphasizes the capacity of the private sector to innovate. That's JUST what I said in my final opinion against a public plan, in my July 22 post. I see the potential for hospitals and doctors to integrate into stronger networks that encourage innovation under a system of competing regulated private insurance. That's our best hope of being able to evolve a system that balances quality, costs and access to care.
One point missing from the Thaler article is that to be on a "level playing field" with competing private plans, the amount that the public plan pays to physicians must NOT be tied to the Medicare Part B fee schedule, as is currently in the bill passed by the House last month. That bill requires that physicians be paid the Medicare fee schedule +6% (in hopes that will appease the AMA). But that amount is sure to be held below the amounts that private plans can negotiate. Sounds good on its face, but it strengthens fee-for-service medicine at a time when that mode of operation has been shown to lead to overuse of visits, procedures and tests. It will slow down innovation, and it will drive out private insurers because doctors will have a choice whether they must accept the private insurance fees. If the public plan can piggy back on the Medicare rules for physican fees and participation, it will have a big cost advantage.

Health Reform Debate-- more agreement than you'd think.

2009-08-07T13:33:00.002-04:00

Here is a great interview by Terry Gross of Fresh Air of Paul Krugman of Princeton and Stuart Butler of the Heritage Foundation, on health reform. They agree on most things, such as whether employer health benefits above a threshold should be taxed, whether individuals should be forced to get health insurance, and whether health plans should be regulated so that they must give decent benefits and take all comers.
The one area on which they totally disagree is whether there should be a "public option" offered along side all the competing health plans.
I've already concluded that the public option would add to the long-term drag on true reform of the delivery system that is already caused by Medicare. But, I thought that the two of them made the best case possible for each side, so you should listen. We all need to understand what's at stake with health reform.

Save, Save Save!....er, no...Spend, Spend, Spend!

2009-08-02T20:14:00.002-04:00

Am I the only one tired of the mixed (confused?) signals our economic "leaders" (Larry and Tim and Ben) are sending about what we should do with our money? We Americans have spent ourselves into a debt hole in the past 20 years, courtesy of China, mainly, which has bankrolled us. Just a few months back, we were hearing about the crisis in credit card debt due to our profligate spending on cheap Asian goods over the past 20 years.
Now we consumers are being blamed for the failure of the economy to respond to the gadzillions being poured into it by the government. If we just save it, they whine, then all that spending won't do what they want it to do. Make the economy look better and therefore make THEM look better.
So, what should I do? Here's how I'm thinking about the save vs. spend dilemma. Part of me wants to save save save for the rainy day that I absolutely KNOW in my gut is on the way. That day will bring torrents of inflation, mainly through collapse of the dollar, but also because oil prices will gradually sneak upwards. But, if I save, I must put my money in something that's inflation-proof, and those investments are hard to find. Especially since the big guys like Goldman Sachs chew up idiots like me who might try to invest in commodities. I really do not know how to invest in commodities.
On the other hand, I've wanted a lot of gadgets that look like fun. HDTV, smartphones, laptops, kindles, fitness monitors, new big computer screen, new desktop, Wii, etc. etc. And, new furniture, too. And new PJ's. All of these are made in China now. So, once China makes good on its hints that it will switch its currency away from the dollar, all those goodies will get much too expensive for me. So, I'm on a China spending spree right now.
I'll save later-- my savings will be in the form of higher taxes paid to the government when the bill comes due. Since I can't keep everyone else from spending their stimulus-gotten dollars on cheap China, and since I'll have to share in the forced saving known as paying back government debt through taxes, I might as well have a few gizmos to show for it.

Warning Signs of Serious Swine Flu in all patients

2009-08-01T11:05:00.007-04:00

WHO just published guidelines for patients to know whether and when H1N1 (aka swine flu) influenza has turned nasty and now requires immediate attention by medical professionals. The title is "pregnant women", but scroll down to last section, which deals with all patients. Here they are for easy access in the coming months (September and later) when the swine flu is expected to hit USA hard again.

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

2009-07-29T08:58:00.004-04:00

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!

Canada to study Vitamin D and Swine Flu!

2009-07-27T20:31:00.007-04:00

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.)

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

2009-07-22T09:47:00.004-04:00

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!

2009-07-22T09:20:00.004-04:00

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!

How to Contact the White House

2009-07-21T09:27:00.003-04:00

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????

2009-07-21T09:11:00.004-04:00

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.

Health Reform- Capping the Employer Tax Benefit

2009-07-09T20:16:00.003-04:00

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."

Health Reform Kennedy Style

2009-07-07T09:41:00.006-04:00

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.

Three most important health reform questions

2009-07-03T09:22:00.009-04:00

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

should employer plans enjoy unlimited tax deductions for health benefits; and should employers who don't offer insurance be taxed?
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.)
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.

What your doctor should know to do about Swine Flu

2009-06-26T08:51:00.005-04:00

Sister Janet tells me that Swine Flu (or, if I were more PC, "novel H1N1") is the scourge of the Chicago area right now. Probably everywhere, but who's counting? While number of cases reported seems low, that's because little testing is going on. So, anyway, suppose you or your kid gets sick with flu like symptoms, especially including gastro stuff (almost 40% of cases), here are two good guidelines for how you should be handled by doctors and emergency rooms. These are intended for doctors, but I can read them, so you can too. We should, having lived long enough by now, know that doctors and hospitals don't always follow best practices (witness the high rates of hospital-acquired infections in this country!)

First is World Health Organization's Patient Care Checklist. You can take it with you to the ER and keep yourself occupied while waiting to be seen.
Second is the CDC's guidelines for use of anti-viral drugs in children and adults.

I got these sources from the University of Minnesota's CIDRAP daily on-line newsletter. If you're a health nut, you'll really enjoy getting it too. I knew about the Nestle's chocolate chip cookies real fast.

Pharma's "gift" to the Medicare patient.

2009-06-22T17:20:00.004-04:00

Perhaps you heard -- Pharma just got together with AARP to announce that they will offer a 50% discount on patent-protected brand name drugs for Medicare patients once the patient reaches the "doughnut hole" -- the point in annual spending ($2700) when Medicare takes a breather and the patient is responsible for 100% of his drug bill. (Later in the year, once the patient's total spending (out-of-pocket + Medicare-paid) reaches $6154, catastrophic coverage kicks in, and Medicare gets generous again). Though the details are sketchy, one account says that all the savings will go to the patient. That is, the full cost of the drug will count toward achieving the catastrophic limit, so the patient will get credit for the other half of the drug's price, too. The Medicare plan won't gain any savings. Sounds like a good deal for the patient, but not if it takes the pressure off drug companies to keep total prices down, and if it induces patients and their docs to order more brand name drugs. Then the cost of the drug plans will rise, and both the gov't (us) and Medicare enrollees will pay more in premiums. Also, how can the administration be considering using the savings to pay for health reform when there don't appear to be any savings to the program itself?

If, however, Pharma means that the patient's actual spending will be what counts toward the catastrophic limit, then the patient won't gain as much, and he won't gain anything if the total costs of his drug coverage take him to the catastrophic limit. He'll just get to the limit more slowly during the year.

So, it seems for now that everyone is being duped but the drug companies. Or is everyone (AARP, Prez Obama, drug industry) trying to take credit for something that's too byzantine for us to follow?