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Sunday, September 15, 2013

Health Care Reform Articles - September 15, 2013

SEPTEMBER 13, 2013, 12:01 AM

Waste vs. Value in American Health Care

By UWE E. REINHARDT
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
Give economists a drink – or not – and with a straight face they will tell you that the American health-care systems is one of the highest value-added sectors in the economy (see, for example, the book “Measuring the Gains From Medical Research,” edited by Kevin M. Murphy and Robert H. Topel.)
Give economists another drink – or not — and with the same straight face they will tell you that our system is alarmingly wasteful.
To illustrate, in a presentation, “The Value Equation in Health Care,” delivered at a conference at Rice University in 2007, the Harvard economist David Cutler, who has studied these issues extensively, noted: “I highlight two fundamental facts about health care. The first fact is that the average value of medical advance is very high,” and the second is that “most estimates suggest that about 20 percent to 30 percent of medical spending could be eliminated with no adverse effects on patient outcomes.”
Lest you wonder what economists like Professor Cutler are talking about, behold the chart below.

The horizontal axis denotes average health spending per capita. The vertical axis represents “quality-adjusted life years,” or QALY‘s, a widely used outcome metricin health-services research.
When economists speak of the health system as a “high average-value sector,” they have in mind an average such as the distance AB in the chart divided by the distance OB, but with a monetary value – very often $100,000 or more – put upon the QALY (see, for example, this article). Of course, what a QALY actually is worth leads one quickly into a philosophical and ideologically charged thicket, especially when someone asks whether a QALY has the same monetary value regardless of on whom it is bestowed. I will delicately sidestep that issue here, although I welcome those who wish to offer their views on it.
When economists talk about waste in our health system, they have in mind not an average, but what they call the marginal (incremental) benefits to the marginal (incremental) spending on them. The ratio is negative on the input-output curve beyond A. That segment represents not only pure, unambiguous waste, but waste that is inimical to the health of patients – e.g., unnecessary surgery or imaging or unwarranted drug therapy with antibiotics.
But in many economists’ minds – and in quite a few minds of clinicians and management consultants, there is waste also in the almost flat but still upward-sloping segment in the curve, say, from C to A. That incremental spending is called wasteful in the sense that the monetary value imputed to the few QALY’s added by the extra spending is judged below the amount of that added spending (EB on the horizontal axis).
Thus speak economists when they are in a vertical position and healthy.

Rich Man’s Recovery


By 

A few days ago, The Times published a report on a society that is being undermined by extreme inequality. This society claims to reward the best and brightest regardless of family background. In practice, however, the children of the wealthy benefit from opportunities and connections unavailable to children of the middle and working classes. And it was clear from the article that the gap between the society’s meritocratic ideology and its increasingly oligarchic reality is having a deeply demoralizing effect.
The report illustrated in a nutshell why extreme inequality is destructive, why claims ring hollow that inequality of outcomes doesn’t matter as long as there is equality of opportunity. If the rich are so much richer than the rest that they live in a different social and material universe, that fact in itself makes nonsense of any notion of equal opportunity.
By the way, which society are we talking about? The answer is: the Harvard Business School — an elite institution, but one that is now characterized by a sharp internal division between ordinary students and a sub-elite of students from wealthy families.
The point, of course, is that as the business school goes, so goes America, only even more so — a point driven home by the latest data on taxpayer incomes.
The data in question have been compiled for the past decade by the economists Thomas Piketty and Emmanuel Saez, who use I.R.S. numbers to estimate the concentration of income in America’s upper strata. According to their estimates, top income shares took a hit during the Great Recession, as things like capital gains and Wall Street bonuses temporarily dried up. But the rich have come roaring back, to such an extent that 95 percent of the gains from economic recovery since 2009 have gone to the famous 1 percent. In fact, more than 60 percent of the gains went to the top 0.1 percent, people with annual incomes of more than $1.9 million.
Basically, while the great majority of Americans are still living in a depressed economy, the rich have recovered just about all their losses and are powering ahead.

Republican healthcare, purity stances complicate image makeover

By Cathleen Decker
7:00 AM PDT, September 13, 2013


Two unrelated occurrences — one in Washington, one in California — conspired this week to reinforce the Republican Party’s struggle to gain the up-and-coming voters it needs for long-term survival. And it also underscored the value Republicans place on purity, often to their electoral detriment.
In Washington, concern deepened about a threat by conservative Republicans in the House to shut down the government — in defiance even of their leaders’ desires — unless Congress explicitly cuts off funding for the nation’s new healthcare law. The insurance marketplaces established by the law, and championed by President Obama over GOP objections, are due to go into effect Oct. 1, the same day the new fiscal year begins.
In California, the team running the Republican gubernatorial effort of Abel Maldonado departed the campaign, leaving the candidate with almost no money, staff or establishment backing as he tries to take down a popular Democratic governor next year.
The Washington developments certainly have a higher profile. Some party leaders have noted the clanging disconnect between the party’s stated desire to broaden beyond its base of mostly white voters, and its repeated attempts to kill the new healthcare plan. While it is being presented as principle — the need to halt a government overreach — the absence of any sort of proposed replacement  lends a hostile cast. That could well be the take-away among black voters — Obama’s strongest supporters — and Democratic-leaning Latinos, the burgeoning voter bloc both parties desire.
An August poll by the Kaiser Family Foundation showed that views of the healthcare plan — derided as “Obamacare” by opponents — differed widely by ethnic group. Among whites, 52% opposed it and only 30% supported it. Views of Latinos were opposite, with 52% favoring it and 25% opposing it. Among blacks, 63% were in favor and 17% opposed.
Some of the appeal may be partisan — support for the plan may grow out of regard for the president. But it is also true that healthcare is a huge issue in many minority communities. An October 2012 survey by Pew Research Center’s Hispanic Trends Project showed that healthcare was listed as an “extremely important” issue by 50% of Latino voters, trailing only narrowly behind education and jobs


Getting radical in patient care safety — Part 2

By Dr. Erik Steele,
Posted Sept. 12, 2013, at 12:35 p.m.
I used to think I was Dr. Wizard Oz — all knowing, and all powerful. Twenty-five years in practice have hauled back the green curtain from my illusion and exposed this truth: my patients are better off if I share the power in patient care with patients, nurses and other members of the patient care team.
So is the patient. In fact, there is growing evidence that when everyone else in the patient care system always defers to the doc, care may be less safe than if others feel empowered to challenge physician authority at critical times and on critical issues. The best health care organizations are now teaching patients and patient care staff to question — and even challenge — physicians when those nonphysicians think the physician is making an error in the patient’s care, and teaching physicians to welcome those challenges. The result can be a substantial reduction in medical errors, safer patients, more satisfied health care staff and better physicians.
It seems paradoxical that patient safety could be improved by taking authority and power away from that member of a patient care team with the greatest knowledge about patient care — the physician. That’s like improving airline safety by taking authority away from the captain — the most senior member of the crew — and giving some to the less experienced people in the cockpit. Exactly, and that is just what airlines have done. The result of this change in cockpit culture has been a dramatic improvement in airline safety. This and other airline safety initiatives have taught safety experts everywhere that complex systems such as health care are less error prone when one person does not have so much authority and power that everyone else is afraid to challenge the mighty Dr. Oz.
The history of airliner crashes is replete with disasters in which the crew knew that the captain was making risky decisions but said nothing, or failed to say something repeatedly and emphatically, because they were afraid to challenge the king of the cockpit. So is the history of medical errors. In fact, about 40 percent of the time investigations of medical errors find that someone involved in the patient’s care was worried an error might be made but failed to intervene, often because they were afraid to effectively challenge the physician or some other more senior member of the care team.
One of the main reasons people are reluctant to speak up when they know something is going wrong is what psychologists call the Power Distance Index (PDI, power distance, or power ratio), meaning the perceived difference in the power held by each of two people in a relationship. The greater the difference, the more reluctant those with less perceived power are to challenge those with more. That’s especially true if those with more perceived power are seen as likely to be unwelcoming or dismissive of anything that seems like a challenge, or to retaliate against those they see as challenging their authority.
The need to tackle power differentials goes beyond patient safety. Patients empowered with more knowledge about their options for treatment of a given health problem often choose less aggressive interventions than those recommended by their physician, and may be more likely to forgo futile end-of-life care. Less of a power distance between patient and physician can therefore mean more shared decision-making in patient care.

AFL-CIO reaffirms commitment to single payer, demands fixes to ACA

By Kay Tillow
Single Payer News, Sept. 12, 2013              
The just-concluded AFL-CIO convention in Los Angeles reaffirmed its commitment to a single-payer health care system while demanding that the Affordable Care Act (ACA) be fixed to protect Taft-Hartley (multi-employer) plans, to end the excise tax, to make employers cover workers who average 20 hours a week, to require construction companies with five or more employees to provide health care, to penalize companies who dump their workers onto Medicaid, plus more.
Some of the debate on the resolution can be seen here:
Full text of the resolution can be found here:
Distributed by All Unions Committee for Single Payer Health Care--HR 676, c/o Nurses Professional Organization (NPO), 1169 Eastern Parkway, Suite 2218, Louisville, KY 40217. Phone: (502) 636-1551. E-mail: nursenpo@aol.com. http://unionsforsinglepayer.org
Other media coverage:


Obamacare Insurance Co-ops At The Starting Gate

TOPICS: INSURANCE, MARKETPLACE, HEALTH REFORM, STATES, UNINSURED
By JAY HANCOCK
KHN Staff Writer
SEP 12, 2013
They have rented offices and zero customers. All their capital is borrowed. They’re trying to sign the kind of expensive, chronically ill individuals  that insurers have avoided for decades. In three weeks they face mighty competitors with a hundred times the resources.
But the 24 insurance-company startups created by the Affordable Care Act say they’re ready to battle the establishment, stay in business and change health care.
“What we’re doing is a big part of the ACA story,” said John Morrison, president of the National Alliance of State Health CO-OPs. “We bring a completely different paradigm to health care finance. We’re not interested in making as much money as we can. We’re not interested in making profits. What we are interested in is making consumer patients healthy and saving money.”
Morrison and other co-op officials talked to reporters Wednesday while in Washington for a NASHCO meeting.
The health law designed co-ops to give competition to Blue Cross, Aetna, UnitedHealthcare and other commercial insurers. Private, nonprofit co-ops emerged as a compromise after Congress balked at establishing a government-run “public option” insurer.
Individuals and small employers will be able to buy co-op policies through the ACA’s online marketplaces — along with plans offered by other carriers — in the two dozen states where they do business. The marketplaces are scheduled to open Oct. 1. The original idea was to have a co-op in every state, but Congress cut startup funding.
Maine Workers Begin to See Changes in Coverage Under ACA
09/13/2013   Reported By: Patty B. Wight

Trader Joe's, the popular national grocery chain, announced recently that, as of January 2014, it will discontinue health insurance coverage for part-time employees, and direct them to buy health insurance on the new online marketplace that opens next month under the Affordable Care Act. Trader Joe's is not the first business in Maine to change its employees' benefits or hours in light of the new health care law, as Patty Wight reports.
For months, news headlines have warned of hiring freezes and cuts to employees' hours, as businesses brace for the Affordable Care Act. The federal law requires businesses with at least 50 full-time employees to provide health insurance to those working full-time hours, which, under the law, is defined as 30 hours a week or more. 

There are even reports of possible new hour restrictions in the public sector, says Eric Conrad of the Maine Municipal Association. "Yes, we are hearing anecdotally that if towns and cities have part-time employees that are, let's say, in the 30- to 35-hour range, that they are considering cutting those to below 30 hours to reduce their health care costs," Conrad says. "That is being talked about."

 Conrad says it's important to note, however, that in Maine, relatively few municipal employees are part time. In the private sector, says Dick Grotton of the Maine Restaurant Association, some businesses are also considering cutting employee hours.


On Campus, a Faculty Uprising Over Personal Data

By 
IMPROVING health while holding down health care costs is the kind of having-your-cake-and-eating-it combination that most people can get behind. In fact, both ideas are embedded in the Obama administration’s Affordable Care Act. But an uprising among faculty members at Pennsylvania State University over a new employee wellness plan is challenging at least some of the methods designed to achieve those aims.
Penn State administrators quietly introduced the plan, called “Take Care of Your Health,” this summer in the deadest part of the academic calendar. But that didn’t prevent some conscientious objectors from organizing a protest online and on their campuses, culminating last week in an emotionally charged faculty senate meeting. The plan, they argued, is coercive, punitive and invades university employees’ privacy.
The plan requires nonunion employees, like professors and clerical staff members, to visit their doctors for a checkup, undergo several biometric tests and submit to an extensive online health risk questionnaire that asks, among other questions, whether they have recently had problems with a co-worker, a supervisor or a divorce. If they don’t fill out the form, $100 a month will be deducted from their pay for noncompliance. Employees who do participate will receive detailed feedback on how to address their health issues.
At a university where some employees earn less than $50,000 annually, the faculty members contended that an $1,200 annual surcharge — or $2,400 with a spouse — for nonparticipation amounted to a strong-arm tactic. What’s more, they argued, the online questionnaire required them to give intimate information about their medical history, finances, marital status and job-related stress to an outside company, WebMD Health Services, a health management firm that operates separately from the popular consumer site, WebMD.com.
“You can’t force people to disclose the state of their marriage or fine them $100 a month. That’s just wrong,” Matthew C. Woessner, an associate professor of political science at the university’s Harrisburg campus, told me. “There are ways to have a veneer of wellness without coercing people to hand over their private information to third parties.”
AS medical costs skyrocket, employers who subsidize health coverage are increasingly turning to wellness plans. The theory is that making employees aware of their own health risks could lead them to, say, eat better or exercise more, hindering diseases like diabetes from progressing to stages that are more expensive to treat.
Susan Basso, vice president for human resources at Penn State, said it adopted the wellness program in an effort to slow double-digit annual growth in health expenditures. Penn State is self-insured, meaning that it directly covers the health care costs of about 40,000 employees, spouses and dependents, at an estimated cost this fiscal year of $217 million. The new plan is projected to hold cost increases to 5 percent in 2014, she said, ultimately saving $62.9 million over the next five years.
“What we are telling faculty is that the status quo is not an option,” Ms. Basso told me last Wednesday.

The Annual Republican Crisis

By 
The fiscal year is about to end, so the annual awakening of Tea Party Republicans in the House and Senate is about to begin. Most of the time they sit around and do virtually nothing but gripe (they have made the current Congress the least productive ever), but a new fiscal year finally gives them a chance to govern the only way they know how: by creating a false crisis in order to tear down a piece of the government.
This year, as has been the case so often in the past, their target is President Obama’s health care reform law. If it is not repealed or defunded or delayed or otherwise left bleeding in the public square, they will not pass a spending bill needed to keep the government open past Sept. 30. And if that doesn’t cripple the health law (which it won’t), they will resort to the far more serious threat of default, refusing to raise the nation’s debt ceiling, no matter the catastrophe that would cause.
It has been clear for months that House Republicans are not going to agree to the Senate’s reasonable spending plan for 2014, one that replaces the damage of the sequester with a mix of revenue increases and less-harmful cuts. The House budget, in fact, calls for cuts to below the sequester level. The best that can be hoped for is a stopgap measure, known as a continuing resolution, to keep the government running through mid-December at this year’s inadequate level.
But on Wednesday, with time running out, House leaders announced they couldn’t manage even something as simple as that. Speaker John Boehner and Eric Cantor, the majority leader, had come up with a far-fetched scheme to placate the radicals in their coalition by attaching a provision to the spending resolution that would force the Senate to vote on defunding health reform. The Senate would, of course, instantly reject the health care language, but it could then approve the spending measure to prevent a shutdown.
The Republican extremists killed the idea, leaving the scheme without enough votes. They are no longer interested in symbolic blows against the health law; there have already been scores of those votes. They actually think they can get the Senate, and ultimately the president, to approve the defunding of the health law — Mr. Obama’s most important achievement — by threatening to harm the nation and the economy.

Club for Growth takes aim at Obamacare as it continues to take on GOP from the right

By , Published: September 14

The first sign that Republican leaders could not control their new majority came on a vote to help Americans who lose their jobs to foreign workers. House Majority Leader Eric Cantor (R-Va.) considered the measure routine and in February 2011 put it on a list of bills expected to pass without objection.
Enter the Club for Growth. Flush with power after helping to elect 13 House members and defeat two veterans in the Senate, the conservative campaign-finance machine blasted out an e-mail declaring its opposition to extending the 40-year-old retraining program, which it called “inappropriate for a country devoted to free markets and a limited government.”
Within hours, like-minded lawmakers protested. Cantor abruptly canceled the vote in a display of party chaos that was astonishing at the time.
It’s not so astonishing anymore. Since then, the Club for Growth has repeatedly embarrassed House leaders, helping to torpedo Speaker John A. Boehner’s “fiscal cliff” strategy, the recentfarm bill — even bland Cantor initiatives aimed at helping the uninsured and sick kids with cancer. After spending millions to empower the anti-government right, the Club has become the proud sponsor of congressional gridlock.
Now the group is advocating disruption on a grander scale, urging Republicans to wage what some in the party are calling a suicidal campaign to shut down the government unless President Obama agrees to defund his signature health initiative. Last week, Boehner (R-Ohio) cancelled another vote — this time on a plan to keep the government open past Sept. 30 — after the Club and other outside groups complained that it failed to undermine Obamacare.
“Every Republican ran on defunding or repealing Obamacare. This is a test of whether they’re actually going to do what they say they’re for,” said Club President Chris Chocola, a former congressman from Indiana. “What’s the more radical thing to do: Continue to spend more and borrow more from China? Or have the confrontation? It’s never going to get any easier.”
GOP leaders are reworking the measure while Washington braces for another round of white-knuckle deadlines. Meanwhile, Republican strategists are fuming, accusing the Club and its allies of dividing the party and toying with the U.S. economy in a cynical bid to raise cash.
“These are self-perpetuating entities, and if they stop fighting for a cause, the money dries up. So they have to drum up this outrage because it pays their salaries,” said former Arizona congressman Ben Quayle, the son of former vice president Dan Quayle. Ben Quayle narrowly lost his House seat last year after tangling with the Club. “It’s all about how to increase their fundraising,” he said.
Chocola is unapologetic. The Club’s mission, he said, is to advance “economic freedom, not Republicans.”

Insurers limiting doctors, hospitals in health insurance market

Insurers in California's new health insurance exchange are holding down premiums by limiting choices, raising concerns that patients will struggle to get care.

By Chad Terhune
6:34 PM PDT, September 14, 2013
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The doctor can't see you now.
Consumers may hear that a lot more often after getting health insurance under President Obama's Affordable Care Act.
To hold down premiums, major insurers in California have sharply limited the number of doctors and hospitals available to patients in the state's new health insurance market opening Oct. 1.
New data reveal the extent of those cuts in California, a crucial test bed for the federal healthcare law.
These diminished medical networks are fueling growing concerns that many patients will still struggle to get care despite the nation's biggest healthcare expansion in half a century.
Consumers could see long wait times, a scarcity of specialists and loss of a longtime doctor.
"These narrow networks won't work because they cut off access for patients," said Dr. Richard Baker, executive director of the Urban Health Institute at Charles Drew University of Medicine and Science in Los Angeles. "We don't want this to become a roadblock."
To see the challenges awaiting some consumers, consider Woodland Hills-based insurer Health Net Inc.
Across Southern California the company has the lowest rates, with monthly premiums as much as $100 cheaper than the closest competitor in some cases. That will make it a popular choice among some of the 1.4 million Californians expected to purchase coverage in the state exchange next year.
But Health Net also has the fewest doctors, less than half what some other companies are offering in Southern California, according to a Times analysis of insurance data.
In Los Angeles County, for instance, Health Net customers in the state exchange would be limited to 2,316 primary-care doctors and specialists. That's less than a third of the doctors Health Net offers to workers on employer plans. In San Diego, there are only 204 primary-care doctors to serve Health Net patients.
Other major insurers have pared their list of medical providers too, but not to Health Net's degree. Statewide, Blue Shield of California says exchange customers will be restricted to about 50% of its regular physician network.
In response, California officials have been pressing Health Net and other insurers to add more doctors since companies filed their initial rosters in May. The state exchange, Covered California, says it will monitor enrollment closely once it begins next month and it's prepared to step in if problems arise.
"Our interest is in assuring everyone enrolled in a plan has ready access to the clinicians they need," said Peter Lee, executive director of Covered California. "That means if a plan can't serve patients, we'll close it down from taking new enrollment. That is in some ways the nuclear option."
Rather than mere head count, officials say they are scrutinizing what capacity physicians have to accept new patients. And to assist consumers, California will enable people to search for specific doctors online during enrollment to determine what, if any, health plans they will be part of in Covered California.
"Does the doctor have room for one more patient or 40 patients? It's about available seats," Lee said. "We want to make sure every network has enough doctors."
http://www.latimes.com/business/la-fi-insure-doctor-networks-20130915,0,3866885,print.story


Mainers can get help navigating Obamacare

Federally funded workers will fan out to explain options in the insurance marketplace being created by the Affordable Care Act.

By Jessica Hall jhall@pressherald.com
Staff Writer
From lobster wharves and supermarkets to town libraries and public health centers, the topic of health insurance will be inescapable starting Oct. 1.
A team of more than 125 so-called navigators -- essentially, insurance translators -- will blanket the state to help Mainers understand the insurance marketplace being created by the Affordable Care Act.
"We'll go down to the docks. We'll call community meetings. We'll go to the libraries and shopping centers. We'll make ourselves known," said Brian Delaney, spokesman for the Fishing Partnership Health Plan, based in Massachusetts, which is working with the Maine Lobstermen's Association to help explain the new insurance laws to fishermen. "The insurance changes are going to happen. It is imperative to get everyone signed up. It's our job to find everyone, reach out and explain what's changing and how it will affect everyone."
The health insurance exchange, now known as the insurance marketplace, was mandated under the Affordable Care Act, or Obamacare. The marketplaces will be the place for individuals to buy health insurance. Subscribers can sign up from Oct. 1 to March 31 by mail, online or in person with the help of a navigator.
Beginning Jan. 1, Obamacare will require almost all Americans to have health insurance or face tax penalties.
In Maine, the marketplace will feature insurance products from Anthem Blue Cross and Blue Shield and Maine Community Health Options.
Choices will include plans ranging from bronze -- the cheapest, providing coverage for about 60 percent of health care costs -- to platinum, the most expensive plan, covering roughly 90 percent of eligible expenses. Gold and silver plans, which offer different levels of coverage, will also be available.
The Maine Bureau of Insurance expects 5 percent to 8 percent of state residents, or 65,000 to 104,000 people, to purchase insurance on the exchange. The federal government aims to sign up 7 million people in the U.S. in the first year.
That number is expected to grow to 24 million in 2016, according to the Congressional Budget Office.

Bill Nemitz: Time to tell ride service to take a hike

Here's a question for the Maine Department of Health and Human Services that sounds a lot like the question being asked by countless MaineCare recipients who need a ride to and from their medical appointments:
What the hell's taking you so long?
If Maine's new $28.3 million contract with Coordinated Transportation Solutions -- a misnomer if ever there was one -- was followed to the letter, the new "broker" for most of the state's Medicaid-funded transportation services would have been sent packing by now.
The contract, which state officials claim was forced upon them by the federal government (except it wasn't), allows for complaints from no more than 1 percent of the people who rely on Coordinated Transportation Solutions -- henceforth known as "Uncoordinated" -- for health care transportation.
Instead, since the company took over most of the MaineCare transportation program on Aug. 1, the wheels have come off: So many people have either called to complain (or given up altogether) that the state and Uncoordinated can't even provide an accurate number.
But that's not the half of it.
We have the now infamous phone call placed to Uncoordinated last week by state Rep. Matthew Peterson, D-Rumford, during a legislative committee meeting on the unfolding crisis.
"I'm sorry for any inconvenience," said the recorded woman's voice for all the Health and Human Services Committee to hear on Peterson's speaker phone. "Goodbye."




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