Bring It On 2010
With the country seemingly fomenting from one crisis to the next this past year, many of us are looking forward to a new beginning, let’s bring on that extra digit for 2010! This article highlights what one family did to make a difference in a social need, providing a little hope for the holidays.
Nursing Shortage
As the United States population continues to age, more of us will become hospital patients, which is of concern given the current 135,000 nursing vacancies across the country. Despite the economic downturn, a shortfall in nursing supply continues and is expected to grow to 260,000 in the next fifteen years. Which means, when we are older and more vulnerable, who will be there to care for us?
Mid-course correction
Donna grew up a middle child of seven, in the Great Lakes land of Swedes and Norwegians. When she became an adult she had seven children, four of them before age 24. After several cross-country moves she returned to school and completed her R.N. program shortly before her fiftieth birthday. She worked for 25 years as a charge nurse in a community hospital before retiring. During that time she absorbed the changes of many for-profit corporate takeovers and saw a decline in the quality of care due to decreased staffing in the facility. Finally, she retired at age 72, not out of fatigue, but from frustration with the diminishing resources available to care for increasingly more vulnerable patients.
One Person Can Make a Difference
For Donna’s seventieth birthday, a scholarship was created in her name through the Texas Nursing Association. The award was designed to finance nursing school for community college enrollees who are displaced homemakers. The first scholarship recipient was a survivor of both Hurricanes Katrina and Rita and mother of three children. Despite the loss of her home and damage to her school she stayed on track for completion. The second scholarship was just granted in November, to a fifty-year-old woman who is just entering nursing. Each year, Donna contributes significantly to the fund, even though she is now a retiree, but most importantly, helping someone else still inspires her.
One person, one family, reached out to a community to address the need to recruit and train more nurses in the long term. In a more immediate sense, two families are better off now than before. Thanks Mom.
Happy Holidays to all and to all a good night!
Thursday, December 3, 2009
Thursday, November 19, 2009
Retort to Change in Breast Cancer Prevention Protocols
This week, lurid headlines were in all United States papers proclaiming a government charged task force of "experts" recommended rolling back frequency of breast mammograms from annually to once a decade if you are age 40 or wait fifteen years if you are age 35. My first reaction was WTF, followed by; I wonder how much they paid for this study. Since I am twice a breast cancer survivor, I consider myself to be somewhat of an "expert" and I have a health policy background. According to the Center for Disease Control, 74.6% of women in the United States who were forty and older received mammograms in 2005. The latest recommendation published in the Annals of Internal Medicine could have an adverse impact on the mammography rate for American women. In order to be fair, let us examine this from a rational perspective.
The most salacious reason cited for reducing the prevalence of mammography in pre-menopausal women was the potential harm of the screening process. Excuse me, you mean the harm of having to obtain a second mammogram because of careful screening and a potential false positive result? This is a good thing as the level of scrutiny for abnormal breast tissue is high in order to save lives. If these folks are concerned about the radiation exposure, the exposure from the sun is worse and certainly contributes to more incidence of cancer than prophylactic breast radiation. Or perhaps it was the horror of the stereo tactic needle biopsy, about as challenging as a blood draw. What exactly are the harmful effects this panel of experts was talking about, a poke in your boob? Or are women really so shallow that a mark or scar on their breast is more important than surveillance for a potentially fatal disease.
In 1993, when I had my first BC diagnosis, I was told that 6,500 women who were under age forty in the United States died from the disease each year, and that I was an anomaly. I was also given literature on how slow growing the disease was and that it primarily impacted grandmothers. Since I was 35 at the time, I decided to do my own research, finding European data on treatment for pre-menopausal women. I knew several women who had died of this disease at the time and the only thing we had in common was an education and a career, which typically meant late or not-at-all child bearing. In my case there was no family history of breast cancer that was disproportionate with the general population.
The proviso this panel of experts make that high-risk women should obtain mammograms excludes one consideration, we don’t typically know who these people are, unless they have been to an oncologist, which would include mammography. The difficulty in preventing cancer mortality is due in part to the elusiveness of the disease indicators and the optimal way to prevent deaths is to have broad population cancer surveillance. Breast cancer mortality is affected by patterns of early detection and quality of care. According to a recent report in the Cancer Journal for Clinicians, which reviewed breast cancer data from 1996 to 2006, breast cancer mortality is declining in the United States. The article also reviewed global breast cancer data and noted the mortality reduction in breast cancer cases was indicative of the early screening, detection, and therapeutic treatments. Why would the United States want to reduce the gains made in saving lives with this virulent form of cancer?
In 2003, ten years after my initial diagnosis, my oncologist informed me, that I had the same type of cancer in my other breast. At that time I was 46 and based on the recommendations from the aforementioned expert panel, I would have come under the high-risk category and have been able to obtain a mammogram with regularity. Of course I would have died at age 36 without my initial mammogram, since baseline mammograms for women under age 50 are not a recommendation from the panel. At the time of my second diagnosis, I was a graduate student in a top ten public university and a widow with a seven-year-old child. Mammography, which I had annually, was the thing that saved me both times. Was my life not worth saving, according to this panel it was just an anomaly.
Second finding, breast self-exams are not beneficial in diagnosing early stages of breast cancer. Duh, someone finally figured this out. First of all if there is a lump in your breast and you can feel it, that is a big tumor. Mine was two centimeters and I couldn’t feel it at all. Secondarily, many lumps are benign or noncancerous. Finding a lump is not an effective early detection method for cancer.
Thirdly, the inference that the emotional trauma from a potentially false positive mammogram is too overwhelming for females smacks of condescension. Aren’t women responsible for their own health? Why not let women make decisions after they have all of the facts. Note to self, the American Cancer Society does NOT agree with these new recommendations to curtail mammography for women that are under age fifty. For those females who feel that having their boob squeezed is not worth potential cancer prevention, that may not be the most well informed choice, but it their option.
Fourth finding, that mammograms for younger women aren’t reliable because of the difficulty in scanning dense breast tissue. What a bunch of huey! I had less than 17% body fat during my initial diagnosis, which found the presence of abnormal tissue in my first mammogram. Mammograms can be performed for women with all breast densities, especially by the better centers. It is helpful to have your "boob shot" taken at the same center so they become familiar with your tissue anomalies. Also, for those professionals who feel they are challenged with imaging more youthful breast tissue, become competent at your job.
Finally, I am concerned about the implications for insurance reimbursement, which may choose to limit coverage for breast cancer diagnostic procedures for women under age fifty. Hopefully some university professor is currently assigning a cost benefit analysis project about mammograms for women under age fifty. In conclusion, for women who may not feel they can cough up the money for a mammogram, I ask you, what is your life worth? Also, there are nonprofit organizations like the www.cancerlifeline.org that have funds to pay for these services. If in doubt, get a second opinion, and keep asking questions until you feel informed about your own health.
The most salacious reason cited for reducing the prevalence of mammography in pre-menopausal women was the potential harm of the screening process. Excuse me, you mean the harm of having to obtain a second mammogram because of careful screening and a potential false positive result? This is a good thing as the level of scrutiny for abnormal breast tissue is high in order to save lives. If these folks are concerned about the radiation exposure, the exposure from the sun is worse and certainly contributes to more incidence of cancer than prophylactic breast radiation. Or perhaps it was the horror of the stereo tactic needle biopsy, about as challenging as a blood draw. What exactly are the harmful effects this panel of experts was talking about, a poke in your boob? Or are women really so shallow that a mark or scar on their breast is more important than surveillance for a potentially fatal disease.
In 1993, when I had my first BC diagnosis, I was told that 6,500 women who were under age forty in the United States died from the disease each year, and that I was an anomaly. I was also given literature on how slow growing the disease was and that it primarily impacted grandmothers. Since I was 35 at the time, I decided to do my own research, finding European data on treatment for pre-menopausal women. I knew several women who had died of this disease at the time and the only thing we had in common was an education and a career, which typically meant late or not-at-all child bearing. In my case there was no family history of breast cancer that was disproportionate with the general population.
The proviso this panel of experts make that high-risk women should obtain mammograms excludes one consideration, we don’t typically know who these people are, unless they have been to an oncologist, which would include mammography. The difficulty in preventing cancer mortality is due in part to the elusiveness of the disease indicators and the optimal way to prevent deaths is to have broad population cancer surveillance. Breast cancer mortality is affected by patterns of early detection and quality of care. According to a recent report in the Cancer Journal for Clinicians, which reviewed breast cancer data from 1996 to 2006, breast cancer mortality is declining in the United States. The article also reviewed global breast cancer data and noted the mortality reduction in breast cancer cases was indicative of the early screening, detection, and therapeutic treatments. Why would the United States want to reduce the gains made in saving lives with this virulent form of cancer?
In 2003, ten years after my initial diagnosis, my oncologist informed me, that I had the same type of cancer in my other breast. At that time I was 46 and based on the recommendations from the aforementioned expert panel, I would have come under the high-risk category and have been able to obtain a mammogram with regularity. Of course I would have died at age 36 without my initial mammogram, since baseline mammograms for women under age 50 are not a recommendation from the panel. At the time of my second diagnosis, I was a graduate student in a top ten public university and a widow with a seven-year-old child. Mammography, which I had annually, was the thing that saved me both times. Was my life not worth saving, according to this panel it was just an anomaly.
Second finding, breast self-exams are not beneficial in diagnosing early stages of breast cancer. Duh, someone finally figured this out. First of all if there is a lump in your breast and you can feel it, that is a big tumor. Mine was two centimeters and I couldn’t feel it at all. Secondarily, many lumps are benign or noncancerous. Finding a lump is not an effective early detection method for cancer.
Thirdly, the inference that the emotional trauma from a potentially false positive mammogram is too overwhelming for females smacks of condescension. Aren’t women responsible for their own health? Why not let women make decisions after they have all of the facts. Note to self, the American Cancer Society does NOT agree with these new recommendations to curtail mammography for women that are under age fifty. For those females who feel that having their boob squeezed is not worth potential cancer prevention, that may not be the most well informed choice, but it their option.
Fourth finding, that mammograms for younger women aren’t reliable because of the difficulty in scanning dense breast tissue. What a bunch of huey! I had less than 17% body fat during my initial diagnosis, which found the presence of abnormal tissue in my first mammogram. Mammograms can be performed for women with all breast densities, especially by the better centers. It is helpful to have your "boob shot" taken at the same center so they become familiar with your tissue anomalies. Also, for those professionals who feel they are challenged with imaging more youthful breast tissue, become competent at your job.
Finally, I am concerned about the implications for insurance reimbursement, which may choose to limit coverage for breast cancer diagnostic procedures for women under age fifty. Hopefully some university professor is currently assigning a cost benefit analysis project about mammograms for women under age fifty. In conclusion, for women who may not feel they can cough up the money for a mammogram, I ask you, what is your life worth? Also, there are nonprofit organizations like the www.cancerlifeline.org that have funds to pay for these services. If in doubt, get a second opinion, and keep asking questions until you feel informed about your own health.
Wednesday, October 7, 2009
European Country going back to Private Insurance
PBS had an interesting program about The Netherlands Health system last night. The Netherlands (Dutch), has been on the cutting edge of a number of health care issues over the years, including policies for physician assisted suicide for the terminally ill and allocation of resources for maternity and child care. Recently, the Dutch decided to switch from a single payer health care system to an open market, privately insured system, where every resident has a health care budget. This approach could work for the United States, but a number of changes would have to be made to the insurance regulatory infrastructure. This article addresses those system delivery concerns.
Question of Scale
First of all, lets talk about scale, The Netherlands is a tiny country compared to the United States, with excellent public transportation and health services in place for the entire country. In the USA, if you have a car, transportation is excellent, though costly, but access to healthcare in rural and poor areas is much more limited in America than in The Netherlands. Secondly, the country has the same health care insurance standards for everyone in the country, not fifty different standards like the states.
Health Insurance Regulation
In America, the Insurance Commissioner of each state regulates the health insurance industry and though commissioners have a national organization with some standardization recommendations, each state is free to do what it wants for health insurance regulation. There is very little standardization in health care insurance or service delivery in the United States, which is partly the cause of the incredible disparity in cost of care per capita compared to other industrialized countries. Also, about half of the USA health care system is financed by private employer plans and for those employers who choose to take some risk and self insure their health plans, there is an exemption from most of the insurance commissioner regulatory authority. So, this begs the question, how would you standardize the process? The answer is an amendment to the ERISA law, which created this health insurance loophole in the first place. Though it may be easier just to do the pay or play and provide the allowance/subsidy as needed, than to dictate benefit design to these stakeholders.
Lack of Standardization
It is one thing for The Netherlands to take its existing long established policies on basic care, palliative care, and eldercare and change their financing system, but the USA doesn’t yet have standardized policies for health care services. Also, since the administrative cost for private insurance is about three times that of the largest government run program, Medicare, it is hard to see how administrative savings will be made in this scenario. The government has more control to drive system delivery changes with Medicare than it would have with several hundred insurance companies. I can just see the marketing geniuses working on their differentiation campaigns now.
Potential Applications from Netherlands Style Market Based Health Plan
The Dutch have a few options to select from for health care insurance, from basic, to deluxe, and pay an individual cost accordingly. Dental, vision, and luxury services are in the latter package. The United States health care reform movement should require a minimum level of care for all of its eligible residents, including primary care, hospitalization, and prescription drugs. A secondary plan may include basic dental and vision services, whereas the deluxe plan could include better coverage in those areas. One consequence of providing an individual health care allowance is the individual would have to take more responsibility in accessing and choosing health care. Theoretically this policy would reduce unnecessary services.
Evidence Based Treatment
In The Netherlands, new prescription drug and other treatments are subject to an administrative review to determine medical evidence and efficacy of the intervention before approving the treatment. This concept would also be a sound mechanism to thwart excess profiteering in the U.S. health care system. Though some patients may be concerned that they are not receiving the latest treatment, this does not necessarily mean their treatment isn’t effective. There are many instances in health care where a lower tech treatment is just as effective as the more technological one. For example, in wound care, the individual vacuum devices that are affixed to the patients wound are less costly and often more effective than hyperbaric treatment. U.S. citizens have to learn to access quality data when making health care decisions.
Universal Availability of Health Quality Data
Though alpha health care organizations, like Virginia Mason Medical Center, have been integrating quality reporting into their system for years, there is limited national standardization of quality reporting. The NQA or National Quality Association has good data available, but it has not been integrated into all health care delivery systems. Quality measures are complex, but leading health care organizations, like Seton Family of Hospitals, a division of Ascension Health, have incorporated quality into their program development measures for years. If you look at medical standards nationally, each specialty has its own education group that advocates for certain treatment protocols. Perhaps the start of a national standardization movement for basic health care is to create a roll-up of these separate quality measures and continue to refine the process.
Accountability and Reporting
Again, given the scale of The Netherlands compared to the U.S.A. and the fact they migrated from a standardized program initially, their reporting issues are less problematic than for the U.S. migration into a standardized health program. Reporting simplicity, transparency, and auditing would be crucial to maintaining equity in a national health care program. Given the Unites States recent bouts with criminal banking activities and the usual health care fraud scams, the importance of tracking private insurance payers is even more crucial. Since the banking industry has wanted to get into the health care industry for years, this may be their opening, so beware of the foxes in the hen house.
Question of Scale
First of all, lets talk about scale, The Netherlands is a tiny country compared to the United States, with excellent public transportation and health services in place for the entire country. In the USA, if you have a car, transportation is excellent, though costly, but access to healthcare in rural and poor areas is much more limited in America than in The Netherlands. Secondly, the country has the same health care insurance standards for everyone in the country, not fifty different standards like the states.
Health Insurance Regulation
In America, the Insurance Commissioner of each state regulates the health insurance industry and though commissioners have a national organization with some standardization recommendations, each state is free to do what it wants for health insurance regulation. There is very little standardization in health care insurance or service delivery in the United States, which is partly the cause of the incredible disparity in cost of care per capita compared to other industrialized countries. Also, about half of the USA health care system is financed by private employer plans and for those employers who choose to take some risk and self insure their health plans, there is an exemption from most of the insurance commissioner regulatory authority. So, this begs the question, how would you standardize the process? The answer is an amendment to the ERISA law, which created this health insurance loophole in the first place. Though it may be easier just to do the pay or play and provide the allowance/subsidy as needed, than to dictate benefit design to these stakeholders.
Lack of Standardization
It is one thing for The Netherlands to take its existing long established policies on basic care, palliative care, and eldercare and change their financing system, but the USA doesn’t yet have standardized policies for health care services. Also, since the administrative cost for private insurance is about three times that of the largest government run program, Medicare, it is hard to see how administrative savings will be made in this scenario. The government has more control to drive system delivery changes with Medicare than it would have with several hundred insurance companies. I can just see the marketing geniuses working on their differentiation campaigns now.
Potential Applications from Netherlands Style Market Based Health Plan
The Dutch have a few options to select from for health care insurance, from basic, to deluxe, and pay an individual cost accordingly. Dental, vision, and luxury services are in the latter package. The United States health care reform movement should require a minimum level of care for all of its eligible residents, including primary care, hospitalization, and prescription drugs. A secondary plan may include basic dental and vision services, whereas the deluxe plan could include better coverage in those areas. One consequence of providing an individual health care allowance is the individual would have to take more responsibility in accessing and choosing health care. Theoretically this policy would reduce unnecessary services.
Evidence Based Treatment
In The Netherlands, new prescription drug and other treatments are subject to an administrative review to determine medical evidence and efficacy of the intervention before approving the treatment. This concept would also be a sound mechanism to thwart excess profiteering in the U.S. health care system. Though some patients may be concerned that they are not receiving the latest treatment, this does not necessarily mean their treatment isn’t effective. There are many instances in health care where a lower tech treatment is just as effective as the more technological one. For example, in wound care, the individual vacuum devices that are affixed to the patients wound are less costly and often more effective than hyperbaric treatment. U.S. citizens have to learn to access quality data when making health care decisions.
Universal Availability of Health Quality Data
Though alpha health care organizations, like Virginia Mason Medical Center, have been integrating quality reporting into their system for years, there is limited national standardization of quality reporting. The NQA or National Quality Association has good data available, but it has not been integrated into all health care delivery systems. Quality measures are complex, but leading health care organizations, like Seton Family of Hospitals, a division of Ascension Health, have incorporated quality into their program development measures for years. If you look at medical standards nationally, each specialty has its own education group that advocates for certain treatment protocols. Perhaps the start of a national standardization movement for basic health care is to create a roll-up of these separate quality measures and continue to refine the process.
Accountability and Reporting
Again, given the scale of The Netherlands compared to the U.S.A. and the fact they migrated from a standardized program initially, their reporting issues are less problematic than for the U.S. migration into a standardized health program. Reporting simplicity, transparency, and auditing would be crucial to maintaining equity in a national health care program. Given the Unites States recent bouts with criminal banking activities and the usual health care fraud scams, the importance of tracking private insurance payers is even more crucial. Since the banking industry has wanted to get into the health care industry for years, this may be their opening, so beware of the foxes in the hen house.
Friday, September 18, 2009
Pay or Play or Pay and Pay; Obama versus Baucus Health Plans
Baucus Health Plan
Senator Baucus of Montana broke away from his committee to present his approach to a United States health care overhaul. His plan proposes a complicated series of benefit changes in Medicare/Medicaid, along with taxes on health care suppliers, employers, and individuals, depending on the health care scenario. It is like trying to look through depression era glass for the economy in this approach. First of all, I don’t think adding more taxes to an already expensive health care delivery system will make it less expensive. If anything, this type of proposal will drive more people into the government option Obama plan.
Both the Obama and Baucus health plans rely on the employer system for health care financing, as opposed to a program based on individuals selecting their health plan from regional cooperatives, with a tax credit allowance, and some employer allowance. I am often asked why we expect employers to provide health care in the USA and my only answer is, "because that is the way it is now." It would be interesting to hear what employers, both large and small think about their preferred level of contribution to health care for their workers. According to the Employee Benefit Research Institute’s 2009 Health Confidence Survey, 83% of their constituent’s support a public health option. An employer mandate for a national health plan gleans 75% support as well. This organization is a conservative, employer, and insurance based entity, so if this is what their subscribers are saying, Brunhilde has finished her aria, and the curtain is coming down on the current health care marketplace.
Similarities
Similarities between the Baucus and Obama plans include the following features: guaranteed ability to obtain coverage regardless of pre-existing conditions, less predatory pricing based on gender and age, and a reduction in the uninsured populations. These are all good mechanisms to get more people eligible to obtain treatment, so their medical conditions can be better managed and less expensive in the long run.
Differences
Baucus recommends the use of nonprofit health care purchasing cooperatives (Community Health Plans or Health Maintenance Plans), to meet the needs of the uninsured population. Does he mean HMO’s or CHP’s? The problem with spreading the cooperative method to the entire United States population is scale; these are localized primary care provider organizations, not national health care institutions. Also, Community Health Plans deliver primary care at a lower cost than HMO’s although their history is briefer. The Obama public option would have the advantage of existing scale with the government already providing a number of health care services. The government is in a position to negotiate the largest discounts for supplies (theoretically) and prescriptions. Since insurance companies will be prohibited from dropping sick individuals from their plans and they will be required to accept all new applicants, there will be some attrition in the number of providers. Depending on your economic perspective, this is either an intended or unintended consequence of the policy change.
Medicare Reform
Obama’s plan expressly closes the gap in prescription drug coverage for seniors, called the donut hole, which is good. I also like his intent to improve quality and care coordination for Medicare recipients. Most of us will be on Medicare coverage someday and that is when we will experience our highest health care expenses. Since the costs for Medicare are escalating beyond sustainability, as a population we should be reviewing this program for efficiencies as a part of our national health care reform initiatives.
Things I would change in Medicare payments include the following:
-Establish an evidence based payment policy for orthopedic treatments (including hip transplants), that considers value delivered over life expectancy
-Tighten up on medical supply payments for motorized wheelchairs and other areas of abuse
-Optimize government purchasing power for the Medicare prescription program
-Stop paying for Viagra on Medicare (increases the risk of a cardiac event)
-Align reimbursements with optimized treatment protocols, which offer sound clinical results and affordable treatments
Finally, I would also institute a fee schedule for Medicare premiums based on earnings, which was voted down by the AARP years ago. Note to the AARP, look you are relying on the current taxpayers to finance your health care, and you are going to have to compromise a little. Be nice to the young people, we will need them when we are old.
My verdict on the Baucus Plan is that it is DOA, but it certainly contributes to an improved level of discussion on health care reforms, when someone else had the guts to reveal his plan. Like the Greek God of wine, Senator Baucus, I raise a glass to you.
This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission, 9/17/2009
Senator Baucus of Montana broke away from his committee to present his approach to a United States health care overhaul. His plan proposes a complicated series of benefit changes in Medicare/Medicaid, along with taxes on health care suppliers, employers, and individuals, depending on the health care scenario. It is like trying to look through depression era glass for the economy in this approach. First of all, I don’t think adding more taxes to an already expensive health care delivery system will make it less expensive. If anything, this type of proposal will drive more people into the government option Obama plan.
Both the Obama and Baucus health plans rely on the employer system for health care financing, as opposed to a program based on individuals selecting their health plan from regional cooperatives, with a tax credit allowance, and some employer allowance. I am often asked why we expect employers to provide health care in the USA and my only answer is, "because that is the way it is now." It would be interesting to hear what employers, both large and small think about their preferred level of contribution to health care for their workers. According to the Employee Benefit Research Institute’s 2009 Health Confidence Survey, 83% of their constituent’s support a public health option. An employer mandate for a national health plan gleans 75% support as well. This organization is a conservative, employer, and insurance based entity, so if this is what their subscribers are saying, Brunhilde has finished her aria, and the curtain is coming down on the current health care marketplace.
Similarities
Similarities between the Baucus and Obama plans include the following features: guaranteed ability to obtain coverage regardless of pre-existing conditions, less predatory pricing based on gender and age, and a reduction in the uninsured populations. These are all good mechanisms to get more people eligible to obtain treatment, so their medical conditions can be better managed and less expensive in the long run.
Differences
Baucus recommends the use of nonprofit health care purchasing cooperatives (Community Health Plans or Health Maintenance Plans), to meet the needs of the uninsured population. Does he mean HMO’s or CHP’s? The problem with spreading the cooperative method to the entire United States population is scale; these are localized primary care provider organizations, not national health care institutions. Also, Community Health Plans deliver primary care at a lower cost than HMO’s although their history is briefer. The Obama public option would have the advantage of existing scale with the government already providing a number of health care services. The government is in a position to negotiate the largest discounts for supplies (theoretically) and prescriptions. Since insurance companies will be prohibited from dropping sick individuals from their plans and they will be required to accept all new applicants, there will be some attrition in the number of providers. Depending on your economic perspective, this is either an intended or unintended consequence of the policy change.
Medicare Reform
Obama’s plan expressly closes the gap in prescription drug coverage for seniors, called the donut hole, which is good. I also like his intent to improve quality and care coordination for Medicare recipients. Most of us will be on Medicare coverage someday and that is when we will experience our highest health care expenses. Since the costs for Medicare are escalating beyond sustainability, as a population we should be reviewing this program for efficiencies as a part of our national health care reform initiatives.
Things I would change in Medicare payments include the following:
-Establish an evidence based payment policy for orthopedic treatments (including hip transplants), that considers value delivered over life expectancy
-Tighten up on medical supply payments for motorized wheelchairs and other areas of abuse
-Optimize government purchasing power for the Medicare prescription program
-Stop paying for Viagra on Medicare (increases the risk of a cardiac event)
-Align reimbursements with optimized treatment protocols, which offer sound clinical results and affordable treatments
Finally, I would also institute a fee schedule for Medicare premiums based on earnings, which was voted down by the AARP years ago. Note to the AARP, look you are relying on the current taxpayers to finance your health care, and you are going to have to compromise a little. Be nice to the young people, we will need them when we are old.
My verdict on the Baucus Plan is that it is DOA, but it certainly contributes to an improved level of discussion on health care reforms, when someone else had the guts to reveal his plan. Like the Greek God of wine, Senator Baucus, I raise a glass to you.
This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission, 9/17/2009
Thursday, September 3, 2009
Insurance is Not Health Care
To listen to the vitriol regarding health care reforms for Americans, you would think we were in the civil war again. I have noticed a number of trends in blogs and citizens meetings on health care reform and thought I needed to speak up.
Number one, insurance is not health care, it is a financing vehicle for people to pay for health care and this is available to approximately half of the United States population. In order to obtain "private health insurance" many conditions must exist such as:
1) The employer offers health care
2) The employee actually makes a living wage and can afford the premiums
3) A health insurance company serves their area and is accepted by clinicians and hospitals
4) The person is not disabled or otherwise uninsurable
5) Or an individual policy may be available in their region or rural locale
Obviously a lot of employers are not offering health insurance, which is representative of the "private health care system" we have now. As an example, I know someone who worked up to thirty-six hours a week for a nonprofit organization which refused to consider that fulltime employment, so they could exclude that employee from eligibility for the health plan. This represents a market failure in economic terms and thus encourages the government to step in to make up for private market lapses. This is an example of the abuse that happens everyday in business and why the Obama Administration is advocating a pay or play policy for employers. Yes, it is time that employers pay for health insurance or contribute into the regional pool for those workers.
Number two, it does matter when you access health care, because obtaining appropriate care in a timely manner not only saves lives, it saves society money. By refusing to provide basic health care to United States residents we are merely choosing to pay more later for manageable conditions. Examples of these are breast cancer, prostate cancer, prenatal care, hypertension, and diabetes. The current United States health policy, which does not provide fair and equitable access to primary care for all residents, is effectively saying we will pay more later for residents who have these conditions and defer treatment. For example, a young couple, in Arizona, did not have insurance when she became pregnant with twins, yet both of them had jobs. Consequently, she was not able to obtain optimal prenatal care, which resulted in a delay in diagnosis, with potentially tragic results. This lapse in treatment was not their fault, it reflects our shortsightedness as a people that we choose to pay the higher cost for our lack of effective treatment for those who need health care.
Number three, for those Rambo-types who think they can provide for their own health care on a pay-as-you-go basis, I would be willing to bet that you don’t have a chronic disease or a sick child or failing parent. All you have to do is look at the number of individual bankruptcies filed in this country for health reasons to understand the impact on people who were no longer able to pay. A person’s inability to afford health care is not some moral failing, it is a combination of poor health policy and opportunity or just plain bad luck.
Finally, all of the examples I gave have happened to someone in my family. I am sure the rest of you can think of similar examples in your families too. Can’t we put aside partisan differences and work together to improve health care access and delivery for everyone?
Number one, insurance is not health care, it is a financing vehicle for people to pay for health care and this is available to approximately half of the United States population. In order to obtain "private health insurance" many conditions must exist such as:
1) The employer offers health care
2) The employee actually makes a living wage and can afford the premiums
3) A health insurance company serves their area and is accepted by clinicians and hospitals
4) The person is not disabled or otherwise uninsurable
5) Or an individual policy may be available in their region or rural locale
Obviously a lot of employers are not offering health insurance, which is representative of the "private health care system" we have now. As an example, I know someone who worked up to thirty-six hours a week for a nonprofit organization which refused to consider that fulltime employment, so they could exclude that employee from eligibility for the health plan. This represents a market failure in economic terms and thus encourages the government to step in to make up for private market lapses. This is an example of the abuse that happens everyday in business and why the Obama Administration is advocating a pay or play policy for employers. Yes, it is time that employers pay for health insurance or contribute into the regional pool for those workers.
Number two, it does matter when you access health care, because obtaining appropriate care in a timely manner not only saves lives, it saves society money. By refusing to provide basic health care to United States residents we are merely choosing to pay more later for manageable conditions. Examples of these are breast cancer, prostate cancer, prenatal care, hypertension, and diabetes. The current United States health policy, which does not provide fair and equitable access to primary care for all residents, is effectively saying we will pay more later for residents who have these conditions and defer treatment. For example, a young couple, in Arizona, did not have insurance when she became pregnant with twins, yet both of them had jobs. Consequently, she was not able to obtain optimal prenatal care, which resulted in a delay in diagnosis, with potentially tragic results. This lapse in treatment was not their fault, it reflects our shortsightedness as a people that we choose to pay the higher cost for our lack of effective treatment for those who need health care.
Number three, for those Rambo-types who think they can provide for their own health care on a pay-as-you-go basis, I would be willing to bet that you don’t have a chronic disease or a sick child or failing parent. All you have to do is look at the number of individual bankruptcies filed in this country for health reasons to understand the impact on people who were no longer able to pay. A person’s inability to afford health care is not some moral failing, it is a combination of poor health policy and opportunity or just plain bad luck.
Finally, all of the examples I gave have happened to someone in my family. I am sure the rest of you can think of similar examples in your families too. Can’t we put aside partisan differences and work together to improve health care access and delivery for everyone?
Tuesday, August 18, 2009
Overhauling Healthcare Czarina Style
Overhauling Health Care Czarina Style
The United States is known for its wastefulness of consumer goods and energy resources but the excess in our health care system is beyond comparison by all global measures. It is incomprehensible that informed citizens would chose to squander our national resources given a reasonable choice. This dilemma was aptly cited as a national crisis in the National Academy of Sciences Report to President Bush. It is essential that the correct problems be addressed in order to solve resource allocation and equity of distribution in US health care. This analysis explores various perspectives and clarifies what elements have the greatest opportunity for sustained change in the US healthcare system.
Enhancing healthcare and delivering a more affordable product are not mutually exclusive. The polarization that occurs between the public and private healthcare camps only serves to undermine progress for better consumer outcomes. Sean Sullivan’s characterization of prescription drug coverage policies for Medicare patients was inaccurate and inflammatory. Several major insurers in Washington State offer Medicare supplement policies with open enrollment provisions, regardless of insurability annually. Coverage for prescriptions is offered under the contracts. University of Washington Professor Sullivan’s assertion that coverage was only offered by fly-by-night companies to insomniacs was incorrect. Additionally, his assessment that insurance companies put small pharmacists out of business was also inflamed by his personal ire. Insurance companies serve as third party administrators for their clients and they have a fiduciary obligation to provide the most attractive contracts for their clients. This means if they can negotiate an RX discount and offer lower drug prices from a Prescription drug wholesaler, they are going to strike a deal. It is not the responsibility of the insurance company (ies) to support drug stores, large or small. Business failure for any small business is common, because of reduced margins and flawed business plans, but other industries lack the convenience of uncontrollable health care costs for their business failure.
Public perception that everyone in health care is making a profit is grossly in error. Of the remaining insurance companies in the healthcare business, profits are uneven and inconsistent. Profits generated are from business linked to health care contracts, not from the administration of those contracts. Biotechnology companies are another industry in health care that is an extremely volatile sector. Many providers in health care operate on a not-for-profit basis, hospitals, clinics, and insurers. The only segments of health care that seem to be consistently profitable are the drug companies and medical supply companies. Politicians tend to attack industries for sound bites and voter approval rather than the more laborious work of regulatory reform. It is far easier to criticize the health care system and its components than it is to promulgate change.
Much debate ensues about the percentage of United States Health care that is publicly versus privately financed. This is a circular argument as in a democracy the public investment is paid for by private taxpayers. The focus should not be which sector is paying as much as how can we work together to do a better job of administering, selecting, and distributing health care in our country. In order to move forward on a system renovation we need to agree on what as a country, we do well in health care. Below is my list of excellence in health care within the USA:
Creating new technologies to treat specific diseases
Promoting popular healthful practices, like anti-smoking campaigns and dental hygiene
Innovation of health care administration over the world wide web
Minimal wait times for services
A wealth of resources spent on experimental procedures to prolong life
Fairness dictates agreement on what the United States does not do well and here is my selection for the dubious honor:
Cover all citizens
Provide affordable health care to all citizens, but especially in the private sector
Provide excellent pre-natal care regardless of economic circumstances
Judiciously spend money on treatment of viably challenged patients
Develop and distribute effective medical treatments to the population regardless of social demographics
Administer national health resources efficiently
Rather than arguing about whom pays for the present health care system, lets deescalate the situation by identifying what we as a nation agree on for good and poor outcomes and processes in the system. A nonpartisan group with broad representation from the healthcare industry, government, and academia need to work on creating a more efficient system. Polarizing the debate along political lines serves to delay any real reform. An atmosphere of respect would go a long way to gaining greater receptivity for trade offs in reform issues. Health care reform is by no means a win win situation for everybody. Instituting a national mandated health care program could produce the following winner and losers:
Winners
Uninsured
Employees of small employers
Not for Profit Hospitals/health care providers
Senior Citizens
Families
Losers
Small employers(depending on cost)
Unions (one less bargaining chip)
Drug companies
Single employees
This is by no means a complete list, but here is my rational for the categorizations.
Uninsured
First of all, the uninsured, estimated at forty two to forty eight million, would emerge as clear winners in a government mandated health care approach. The uninsured are made up of the unemployed and working citizens who do not have access to affordable healthcare but are not poor enough to be covered by Medicaid. It should also be noted that the nation would win in an indirect fashion by covering these members, as maintenance of health is less expensive to provide than emergency room care, often the only care mode available to this constituency. An additional tax or a reduction in tax spending in another area would be required to cover the uninsured, so to that extent the tax subsidizers would lose here. In my financial calculations of a single payer health system, I estimated it would cost twenty-eight dollars as of October 2002, per paycheck to cover the uninsured.
Employees working for Small Employers
Small employers are least able to pay for employee benefits and are less likely to subside family health care costs, so I believe employees of small employers would gain more from a nationally mandated proposal than their employers. Small businesses would fight this mandate tooth and nail with the prediction that millions of jobs would be lost due to the increased cost of the new tax. In truth, this would only adversely affect the employers who are not taking care of their employees. Other small employers may find the single payer plan to be less costly than current options and simpler administratively. For industries like farming, which employs a significant migrant worker population we would expect the price of food to increase in the USA or a reduction in local jobs in that industry.
Large Employers
I am defining large employers as those with 500 or more employees. It is my belief that these businesses would benefit from the simplicity of a single payer plan and the cost would not exceed what they are already paying. The existence of Leapfrogsuggests that large employers are very concerned about the present health care system of public private resources effectively managing health care. Large employers would also win because a mandated benefit would remove some of the power of unions to dictate benefits and costs to corporations. Conversely, I perceive the unions would lose because they would lose a bargaining chip. Labor unions are already suffering from lack of differentiation and loss in membership, so a national healthcare policy would only exacerbate the problem.
Hospitals
For purposes of analyzing the impact of a uniform adequately funded national healthcare program, I am only addressing hospital outcomes. Presently under the hodgepodge funding arrangement, hospitals are struggling to survive, especially in rural areas. With a guarantee of funding, assuming fair DRG schedules, stability would enhance this sector of the industry. It is possible for profit hospitals could lose some margin, but that would depend on how they marketed their services. A single payer system would not mandate that hospitals be not-for-profit. Ancillary services like cosmetic surgery could still be paid for on a private basis. Virginia Mason in Seattle Washington has an extensive cosmetic surgery business for example. Hospitals that have excellent outcomes could be selected as magnet facilities for certain procedures and may not have to spend as much money on promotion, so they could win as well. Hospitals with poor outcomes or redundant services would lose and potentially close in an economically efficient system. It would probably take years to achieve this result.
Senior Citizens and RX Use
Presently senior citizens spend about 25% of their income on prescription drug costs. There are several reasons for this hardship; drugs are a favored method of treatment in the USA, an aging population, and the high cost of prescriptions due to financing of research and corporate profits. If a single payer health care system were in place, the drug developers would not be able to charge whatever they want for medications. This would lower the cost to seniors and other RX users. Of course the well financing corporate darling drug companies, who have consistently produced profits of 20%, would lose in this proposal. Their argument would be we couldn’t finance research to save lives if we don’t have the ability to recoup our initial investment. Some would argue they would be forced to leave the USA to produce their products, so jobs would be lost. Still, because of the degree of education and expense in developing these biotech facilities, they are all near major academic medical centers, so it is doubtful all of the drug companies would leave. Finally, France is a major developer of new drug therapies, so invention is possible with a socialized heath care approach. Invention and public health are not mutually exclusive.
Families
One could argue that citizens with families would benefit more under a single payer government mandated health care approach than childless employees. Based on my calculations, the average increase in payroll tax would be seventy-two dollars per pay period, which is less than the cost of providing family health coverage in private employer plans. Most employees are paying several times that amount to cover their dependents for insurance. So, families would be clear winners. Childless citizens may argue they are not getting the requisite benefit, but the increase in payroll tax is no different than the subsidy of lower income retirees and widows with Social Security Benefits now. The SSI and Survivors benefits are disproportionately geared to provide a greater income replacement ratio to citizens earning less than the social security cap. In other words, a low-income worker will have a higher income replacement ratio than a higher earning worker.
Where do we go from here
The solution to get all of these disparate groups invested in the idea that a single payer reform is a viable idea is to be ready to bargain and offer some trade offs. My suggestion is don’t try to have the government take over everything, at least not initially. This would be politically explosive and untenable. I suggest that providers continue to operate in their current form, but the coalition of public and private interests decides on the mandated benefit levels and sets prices. So, the government lays the ground rules for what is acceptable. Doctors and hospitals can continue to operate in their current form, but without the billing hassles for reimbursement and greater economic security from tort reform and price regulations. I also suggest that all present forms of government provided healthcare stay the same, but with improved funding for the poor. However, the administration of all nongovernment health care plans would change in my proposal as health czar. I am advocating a government contract for private administration of a nationalized heath care program. This would appease the major insurance companies who have invested millions in infrastructure for claims payment systems and eliminate the weak organizations. It would allow private industry to raise capital for a paperless conversion for claims payment, with all citizens enjoying the benefit. I am envisioning regional health administrators, with perhaps seven regions in the United States. This would also give the citizens the security of knowing that everything wouldn’t change under a single payer proposal. By allowing all parties to be represented at the negotiating table we can invent a more efficient and equitable health care system in the USA. I believe we can achieve close to universal coverage and more affordable coverage for all with the integration of public and private resources.
This article was written by Roberta E. Winter, MHA, MPA in October 2007 and may be reprinted with her permission.
The United States is known for its wastefulness of consumer goods and energy resources but the excess in our health care system is beyond comparison by all global measures. It is incomprehensible that informed citizens would chose to squander our national resources given a reasonable choice. This dilemma was aptly cited as a national crisis in the National Academy of Sciences Report to President Bush. It is essential that the correct problems be addressed in order to solve resource allocation and equity of distribution in US health care. This analysis explores various perspectives and clarifies what elements have the greatest opportunity for sustained change in the US healthcare system.
Enhancing healthcare and delivering a more affordable product are not mutually exclusive. The polarization that occurs between the public and private healthcare camps only serves to undermine progress for better consumer outcomes. Sean Sullivan’s characterization of prescription drug coverage policies for Medicare patients was inaccurate and inflammatory. Several major insurers in Washington State offer Medicare supplement policies with open enrollment provisions, regardless of insurability annually. Coverage for prescriptions is offered under the contracts. University of Washington Professor Sullivan’s assertion that coverage was only offered by fly-by-night companies to insomniacs was incorrect. Additionally, his assessment that insurance companies put small pharmacists out of business was also inflamed by his personal ire. Insurance companies serve as third party administrators for their clients and they have a fiduciary obligation to provide the most attractive contracts for their clients. This means if they can negotiate an RX discount and offer lower drug prices from a Prescription drug wholesaler, they are going to strike a deal. It is not the responsibility of the insurance company (ies) to support drug stores, large or small. Business failure for any small business is common, because of reduced margins and flawed business plans, but other industries lack the convenience of uncontrollable health care costs for their business failure.
Public perception that everyone in health care is making a profit is grossly in error. Of the remaining insurance companies in the healthcare business, profits are uneven and inconsistent. Profits generated are from business linked to health care contracts, not from the administration of those contracts. Biotechnology companies are another industry in health care that is an extremely volatile sector. Many providers in health care operate on a not-for-profit basis, hospitals, clinics, and insurers. The only segments of health care that seem to be consistently profitable are the drug companies and medical supply companies. Politicians tend to attack industries for sound bites and voter approval rather than the more laborious work of regulatory reform. It is far easier to criticize the health care system and its components than it is to promulgate change.
Much debate ensues about the percentage of United States Health care that is publicly versus privately financed. This is a circular argument as in a democracy the public investment is paid for by private taxpayers. The focus should not be which sector is paying as much as how can we work together to do a better job of administering, selecting, and distributing health care in our country. In order to move forward on a system renovation we need to agree on what as a country, we do well in health care. Below is my list of excellence in health care within the USA:
Creating new technologies to treat specific diseases
Promoting popular healthful practices, like anti-smoking campaigns and dental hygiene
Innovation of health care administration over the world wide web
Minimal wait times for services
A wealth of resources spent on experimental procedures to prolong life
Fairness dictates agreement on what the United States does not do well and here is my selection for the dubious honor:
Cover all citizens
Provide affordable health care to all citizens, but especially in the private sector
Provide excellent pre-natal care regardless of economic circumstances
Judiciously spend money on treatment of viably challenged patients
Develop and distribute effective medical treatments to the population regardless of social demographics
Administer national health resources efficiently
Rather than arguing about whom pays for the present health care system, lets deescalate the situation by identifying what we as a nation agree on for good and poor outcomes and processes in the system. A nonpartisan group with broad representation from the healthcare industry, government, and academia need to work on creating a more efficient system. Polarizing the debate along political lines serves to delay any real reform. An atmosphere of respect would go a long way to gaining greater receptivity for trade offs in reform issues. Health care reform is by no means a win win situation for everybody. Instituting a national mandated health care program could produce the following winner and losers:
Winners
Uninsured
Employees of small employers
Not for Profit Hospitals/health care providers
Senior Citizens
Families
Losers
Small employers(depending on cost)
Unions (one less bargaining chip)
Drug companies
Single employees
This is by no means a complete list, but here is my rational for the categorizations.
Uninsured
First of all, the uninsured, estimated at forty two to forty eight million, would emerge as clear winners in a government mandated health care approach. The uninsured are made up of the unemployed and working citizens who do not have access to affordable healthcare but are not poor enough to be covered by Medicaid. It should also be noted that the nation would win in an indirect fashion by covering these members, as maintenance of health is less expensive to provide than emergency room care, often the only care mode available to this constituency. An additional tax or a reduction in tax spending in another area would be required to cover the uninsured, so to that extent the tax subsidizers would lose here. In my financial calculations of a single payer health system, I estimated it would cost twenty-eight dollars as of October 2002, per paycheck to cover the uninsured.
Employees working for Small Employers
Small employers are least able to pay for employee benefits and are less likely to subside family health care costs, so I believe employees of small employers would gain more from a nationally mandated proposal than their employers. Small businesses would fight this mandate tooth and nail with the prediction that millions of jobs would be lost due to the increased cost of the new tax. In truth, this would only adversely affect the employers who are not taking care of their employees. Other small employers may find the single payer plan to be less costly than current options and simpler administratively. For industries like farming, which employs a significant migrant worker population we would expect the price of food to increase in the USA or a reduction in local jobs in that industry.
Large Employers
I am defining large employers as those with 500 or more employees. It is my belief that these businesses would benefit from the simplicity of a single payer plan and the cost would not exceed what they are already paying. The existence of Leapfrogsuggests that large employers are very concerned about the present health care system of public private resources effectively managing health care. Large employers would also win because a mandated benefit would remove some of the power of unions to dictate benefits and costs to corporations. Conversely, I perceive the unions would lose because they would lose a bargaining chip. Labor unions are already suffering from lack of differentiation and loss in membership, so a national healthcare policy would only exacerbate the problem.
Hospitals
For purposes of analyzing the impact of a uniform adequately funded national healthcare program, I am only addressing hospital outcomes. Presently under the hodgepodge funding arrangement, hospitals are struggling to survive, especially in rural areas. With a guarantee of funding, assuming fair DRG schedules, stability would enhance this sector of the industry. It is possible for profit hospitals could lose some margin, but that would depend on how they marketed their services. A single payer system would not mandate that hospitals be not-for-profit. Ancillary services like cosmetic surgery could still be paid for on a private basis. Virginia Mason in Seattle Washington has an extensive cosmetic surgery business for example. Hospitals that have excellent outcomes could be selected as magnet facilities for certain procedures and may not have to spend as much money on promotion, so they could win as well. Hospitals with poor outcomes or redundant services would lose and potentially close in an economically efficient system. It would probably take years to achieve this result.
Senior Citizens and RX Use
Presently senior citizens spend about 25% of their income on prescription drug costs. There are several reasons for this hardship; drugs are a favored method of treatment in the USA, an aging population, and the high cost of prescriptions due to financing of research and corporate profits. If a single payer health care system were in place, the drug developers would not be able to charge whatever they want for medications. This would lower the cost to seniors and other RX users. Of course the well financing corporate darling drug companies, who have consistently produced profits of 20%, would lose in this proposal. Their argument would be we couldn’t finance research to save lives if we don’t have the ability to recoup our initial investment. Some would argue they would be forced to leave the USA to produce their products, so jobs would be lost. Still, because of the degree of education and expense in developing these biotech facilities, they are all near major academic medical centers, so it is doubtful all of the drug companies would leave. Finally, France is a major developer of new drug therapies, so invention is possible with a socialized heath care approach. Invention and public health are not mutually exclusive.
Families
One could argue that citizens with families would benefit more under a single payer government mandated health care approach than childless employees. Based on my calculations, the average increase in payroll tax would be seventy-two dollars per pay period, which is less than the cost of providing family health coverage in private employer plans. Most employees are paying several times that amount to cover their dependents for insurance. So, families would be clear winners. Childless citizens may argue they are not getting the requisite benefit, but the increase in payroll tax is no different than the subsidy of lower income retirees and widows with Social Security Benefits now. The SSI and Survivors benefits are disproportionately geared to provide a greater income replacement ratio to citizens earning less than the social security cap. In other words, a low-income worker will have a higher income replacement ratio than a higher earning worker.
Where do we go from here
The solution to get all of these disparate groups invested in the idea that a single payer reform is a viable idea is to be ready to bargain and offer some trade offs. My suggestion is don’t try to have the government take over everything, at least not initially. This would be politically explosive and untenable. I suggest that providers continue to operate in their current form, but the coalition of public and private interests decides on the mandated benefit levels and sets prices. So, the government lays the ground rules for what is acceptable. Doctors and hospitals can continue to operate in their current form, but without the billing hassles for reimbursement and greater economic security from tort reform and price regulations. I also suggest that all present forms of government provided healthcare stay the same, but with improved funding for the poor. However, the administration of all nongovernment health care plans would change in my proposal as health czar. I am advocating a government contract for private administration of a nationalized heath care program. This would appease the major insurance companies who have invested millions in infrastructure for claims payment systems and eliminate the weak organizations. It would allow private industry to raise capital for a paperless conversion for claims payment, with all citizens enjoying the benefit. I am envisioning regional health administrators, with perhaps seven regions in the United States. This would also give the citizens the security of knowing that everything wouldn’t change under a single payer proposal. By allowing all parties to be represented at the negotiating table we can invent a more efficient and equitable health care system in the USA. I believe we can achieve close to universal coverage and more affordable coverage for all with the integration of public and private resources.
This article was written by Roberta E. Winter, MHA, MPA in October 2007 and may be reprinted with her permission.
Subscribe to:
Posts (Atom)