The New York Times recently reported on Health Reform Private House Parties. At this particular party, the participants easily sided with the angels: health care is a right, insurance should cover everything and coverage should be available from government and businesses. There, that was easy. Bet they had a nice time.

Partygoers were not asked for solutions and the devil is always in the details, so let’s use my favorite – flu shots.

First, the New York Times reported that party participants quickly agreed that “…health care was a right…” It makes me wonder; if health care is a “right,” what of “responsibility”?

- If I have a “right” to flu shots to help prevent flu disease, do I have a “responsibility” to get them to protect myself, reduce my medical care costs, improve economic productivity and protect others around me?
- If I don’t get the shot, infect others and cause them to be ill, am I responsible for the cost of their care?
- If others I infect miss work, am I responsible for the cost of temporary workers or losses incurred by their employer? Am I responsible to the government for the loss in taxable productivity?
- What if they die as a result of the flu I transmit to them? Am I culpable?

Second, participants also agreed “…that insurance should cover ‘everything,’ not just some services….”
- If a flu shot is covered and I choose not to get one, should I be required to pay for any doctor visits and medicines I need?
- Should my employer have the right to charge me for the temporary help that might need to be hired to replace me on the job?
- Should Uncle Sam have the right to tax me for earnings I would have made if I had been on the job?
- Should the cost of something so reasonably priced be covered for everyone? Really, I mean everyone? Even the wealthy who can well afford the cost?

Third, participants agreed that “…coverage should be readily available from the government, as well as from employers….” They agreed that individuals and businesses should have to pay a “small health care tax” to fund care.
- Who are they kidding, “small health care tax?” Have they looked at cost projections lately?
- And what about non-coverage barriers? Coverage is only one barrier to care. Ask those in rural areas, anyone not fluent in English or medically literate.

And yes, I’m still harping on flu shots. The season is not nearly over and there are plenty of doses left to protect the nation from the $87.1 billion – or more – that flu could cost us this winter.¹

1. Molinari NA, Ortega-Sanchez IR, Messonnier ML. The annual impact of seasonal influenza in the US: Measuring disease burden and costs. Vaccine 2007;25:5086-5087.

Two reports recently released by the Congressional Budget Office, Key Issues in Analyzing Major Health Insurance Proposals, and Budget Options, Volume 1: Health Care, have dominated discussions this week.

Jane Zhang of the WSJ reported:

The Congressional Budget Office analyzed 115 options to change health care, some costly and others that would save the government and consumers some money.
…
Among the findings:

- If no changes occur, CBO says health care spending will rise to 25% of GDP by 2025 from 16% last year.

- If the federal government required all employers with more than 50 workers to provide insurance or pay a penalty, federal revenue would increase by $13 billion in four years and $47 billion over nine years.

- Allowing non-federal workers and companies to buy into the Federal Employees Health Benefits Program would cost the federal government about $2 billion over four years and $6.2 billion over nine years.

Ezra Klein explained the importance of these reports and the impact they could have on healthcare reform plans:

How do we decide how much a government program costs? It’s an essential question. Programs need prices, because the government has to produce a budget. But pricing legislation in advance is impossible… But you still need a number. So Washington operates amidst a tacitly agreed-upon imprecision. What the CBO says, goes. “In this town,” says Henry Aaron, a senior economics fellow at the Brookings Institution, “it’s not infrequent to hear people say it doesn’t make any difference what it really costs. It only matters what CBO says it costs.”

The books that the CBO released this week are essentially a guide to the CBO’s scoring process. They tell congressmen, in advance, how the Number will be built. The Wonk Room and The New York Times are focusing on the equations. But they’re not what’s changed. Rather, the difference is that Congress knows what they’ll be in advance. The scoring process will still be a minefield, but now legislators will have a map. There won’t be a situation analogous to 1994, when the White House was shocked by an unwelcome assumption and their legislation was mortally wounded by a staggering price point. Obama and his allies in Congress, along with Orszag’s help, will be able to build a bill able to survive the scoring process. They can, effectively, decide their own Number.

(more…)

Having received the diagnosis of stage 4 pancreatic cancer dad decided that his remaining days should be oriented toward providing him comfort rather than treatment. I had not heard the term (actively dying) before dad was admitted into inpatient hospice. It was a brief stay following his collapse at home. It seemed that he would have preferred and felt safer and more secure to stay longer; perhaps it was the supportive listening and personal care and attention they provided. Or the three meals a day he could have (if only he had an appetite). Or the audiences who came into his room and listened to him conversing fluently in various languages.

But the staff said that he was not yet “actively dying” and there was little (no?) need for him to remain on the inpatient hospice. Yet seeing the sad and fearful look in his eyes, the physician quietly mentioned that perhaps he could remain on the unit one more night. So he stayed another night and then we finalized the plans and arrangements for him to go home with round the clock home health aides.

(more…)

Thursday night on NBC nightly news, Dr. Tim Johnson said “we’re paying for treatments that have never been proven to work” presuming we’re wasting dollars on dubious medical innovations. He described this within the context of the Obama administrations’ announcement of Tom Daschle as the new Health Care Czar who may establish an independent health care board isolated from health care lobbying “interests” and prioritizing US government spending. Within this context, it will likely adopt some process of comparative effectiveness to evaluate health care interventions. Stuart Altman recently said, “we need to move aggressively forward to develop the capacity of this country to do effective comparative research…the nation cannot afford healthcare that is not supported by evidence of sufficient benefit”.

But what really is comparative effectiveness? Comparative effectiveness in the context of health is as old as “medicine itself”, an implicit and explicit comparison of one medical technique to another. If the intervention works (i.e., understanding positive and negative impacts on patient outcomes), than one may translate this into “economic effectiveness”, or “cost-effectiveness” metrics. In our quest to assess value of medical interventions based on meaningful clinical outcomes, decision makers are using a number of well-established academic methodological approaches.

Is this new? No.
(more…)

Ornery Facts

As we work to cover the uninsured, a goal all Americans share, it is key to understand who they are.  Otherwise we will change the law but not achieve the goal. Let’s accurately identify who really needs a new program to provide coverage.

20% are eligible for government programs but are not enrolled. That is almost 10 million people who don’t need a new program; what they need is better outreach by existing programs. Add to that the 19%, or 9 million, that earn more than $75,000. (close to 400% of the FPL for a family of 4) and the 13%, or 6 million, that are eligible for employer coverage (only 5% of whom go uninsured). They don’t really need a new program either. Then there are the 22% who are ineligible because they are here illegally or are in their first five years of legal residence.  That’s 12 million who DO need some type of coverage. So you get some idea of the impossibility of measuring success by “47 million”. (more…)

I believe there are two distinct reasons why medical innovation is threatened in our health care system in the US.

First, I strongly believe that the misaligned payment systems drive inappropriate treatment choices and delivery. This includes differentials in payment by site of service and separate physician payments for procedures that cause inappropriate utilization.

Second, health care policy makers, out of touch with coverage and payment systems, do not truly understand how medical technology fits and is adopted within the framework of coding and coverage systems. It causes manufacturers to force fit new technology into payment and coding systems that have no reflection on true costs or value… To address either explosive volume or costs of a new procedure or service, technology is subject to a threshold of payment and coverage criteria that ultimately causes a true disruption in innovation and dissemination of medical breakthroughs. (more…)

Americans love technology—we will pay almost anything for something that makes communication faster, louder, brighter, or more colorful. We want quick changes and new models, new colors, new brands. In medicine, we demand the same—only the top doctors for our mothers, the best hospitals for our sons, the latest new treatments for our own shaky knees and leaky bladders. We expect it, we demand it. Yet, in medicine, we have a profound tension with balancing cost, risk and newness that translates into enormous policy and political challenges.

For medical technology innovators and physicians that invent and use these tools, we are in the middle of a “policy tug-of-war” that generally comes down to the level of risk we are willing to assume for new treatments. Further, the regulators of medicine assessing the level of risk to the public are besot with too much information vs. too little, with the politics of instant messaging and YouTube clearly influencing how they will ultimately disseminate and manage their decisions equitably.

Our appointed guardians of public safety and risk (the FDA) attempt to monitor new medical therapies and interventions and gather “evidence” knowing that their decisions will affect millions for years, as decisions are rarely intractable in health care. They carefully balance these decisions recognizing that practitioners must have some ability to freely practice to continue to encourage experimentation for the improvement of health in their individual patients.

Having said this, we are now finding that the purchaser is playing an extraordinary role in managing dissemination of care to control escalating costs of providing new innovative interventions. If managing risk through gathering patient evidence works, then of course the regulator (in both private and public sectors) assumes we should logically be able to control costs through the same process. Enter: Evidence-Based Medicine, Coverage with Evidence Requirements, Comparative Effectiveness, Outcomes Research, Cost-Effectiveness Studies, or whatever label you would like to apply to the same fundamental principle: Control Health Care Costs through managing access and volume of services.

As reported in USA Today, critics and proponents of “evidence-based medicine” agree on one thing: It is nearly impossible to remain current on all the latest evidence. Rapid medical innovations are often anecdotal, and when facing a life or death crisis we demand to have anything that would push the envelope to save a loved one. Nonetheless, the budget holders and regulators constantly struggle with maintaining a balance of enough information to allow rapid medical change while at the same time protecting the overall safety of the less-than-perfect medical solutions.

The true problem lies with the budget holder (The Centers for Medicare and Medicaid Services or private payers) using imperfect evidence as a process to control costs and access. Medical innovators are seen as attempting to quickly reach market commercialization at a “risk” to public safety if data are not provided without convincing results. By trying to move technology quickly to the marketplace, this is perceived as “cutting corners” as we negotiate based on the reality that no data will ever completely satisfy the answers related to risk once technology is available outside the investigational settings. We struggle with FDA safety requirements and then are further challenged by each budget stakeholder to provide more evidence as a ubiquitous means to control costs.

In my next post, I will write on Coverage with Too Many Conditions.