Opinions: One on Medicare, one on investor-owned hospitals in Mass

Three items of note in the morning papers:

• A staff editorial in this morning’s NY Times charges says the Republicans are dangerously clueless about how to preserve Medicare.

Republicans claim to be deeply worried about the deficit — their favorite political target, followed closely by President Obama’s relentlessly demonized health care reform. So why are they so determined to overturn one of the central cost-control mechanisms of the new reform law?

Republicans in both the Senate and the House have introduced bills that would eliminate the new Independent Payment Advisory Board, which is supposed to come up with ways to rein in excessive Medicare spending — and stiffen Congress’s spine.

More fodder to demonize now CMS head Donald Berwick, the NYT says: Republicans are also eagerly, and shamefully, pillorying Dr. Donald Berwick, the new head of the Centers for Medicare and Medicaid Services. There are few figures who command greater respect for uniting health professionals and institutions to improve the quality of medical care while reducing costs. That is not stopping these critics from implying — baselessly — that he will introduce socialized medicine and death panels in this country.

  The truth is that Dr. Berwick has praised the socialized British health care system, especially for  its emphasis on primary care. This country certainly needs to do more to develop its primary care system. And he has, rightly, called for an open discussion of the health care rationing that is already widespread in our system. When insurers decline to cover procedures, or high prices screen out low-income people, that is rationing.

Dr. Berwick has endorsed the use of “comparative effectiveness” research to determine which treatments work best. He would use such research to judge whether a new drug or procedure is worth the cost of coverage, a step the reform law shies away from. He does not have the power to change that law. But the issue will have to be addressed at some point if there is to be any hope of restraining medical spending.

Democrats have to counter the Republicans’ demagoguery with facts. Americans need to understand that if Senator (John) Cornyn (of Texas) and others get their way, runaway health care costs will only get worse.

• And an editorial in the Globe says the state needs to scrutinize the sale of the Caritas hospitals to a group of investors to make sure it’s a good deal for everyone:

 THERE ARE good reasons to support the proposed sale of Boston-based Caritas Christi Health Care to New York private equity firm Cerberus Capital Management. In addition to protecting over 12,000 in-state jobs, Cerberus has promised to pay off the non-profit hospital chain’s debt, permanently secure employees’ pensions, earmark $100 million for hospital renovations and expansions, create up to 4,300 new jobs, and increase the system’s footprint by 117,000 square feet. With promises like that, it’s no wonder elected officials including Senators John Kerry and Scott Brown are urging Attorney General Martha Coakley to approve the deal. But before Coakley signs off, she must obtain from Cerberus a clearer sense of how it plans to achieve these goals, and a new commitment of a longer time period before the firm can back out by selling the hospitals.

•  WIth that — and Partners — in mind, check out this story from The Washington Post on the pros and cons of large health care systems, including one in with Roanoke, Virginia. 

ROANOKE — Railroads put this city on the map, but the king of the domain is now health care — or rather, the Carilion Clinic.

Carilion owns the two hospitals in town and six others in the region, employs 550 doctors and has set off a bitter local debate: Is its dominance a new model for health care or a blatant attempt to corner the market?

Carilion says it represents an ideal envisioned by the nation’s new health-care law: a network that increases efficiency by bringing more doctors and hospitals onto one team, integrating care from the doctor’s office to the operating room. The name for such networks, which the new law strongly promotes with pilot programs, is accountable care organizations, or ACOs — providers joining together to be “accountable” for the total care of patients, with incentives from insurers to keep people healthy and costs down.

“We need to fundamentally get off a transaction system where you’re paid for what you do to patients to being paid to care for them,” says Carilion chief executive Edward Murphy.

But skeptics apply a more old-fashioned term to networks like Carilion: monopolies, which they say will make health care even more expensive.

“The only way to decrease costs that truly works is increasing competition, but for some reason in health care, we’re supposed to believe that competition drives up costs,” said ophthalmologist Frank Cotter.

The gap between those two views is at the heart of whether the law succeeds in controlling costs. Meanwhile, the question is creating a schism in the Roanoke Valley, a region of more than 250,000 people that depends on Carilion’s 12,300 jobs but also worries about health-care costs out of proportion to the area’s cost of living.

USA Today on Harvard Vanguard shared appointments, and an aside

Damn — scooped again. Every time  I go to the doctor and see that sign for “shared medical appointments” I say to myself — good story. Then I remember – I should not reports on doctors in the practice where I get care. 

Once when going for a prenatal test at the Univeristy of North Carolina hospital, I lay on the table in a very vulnerable position as a doctor approached me with a very large needle. Didn’t you interview me for a story once?  he asked. The giant, disorganized Rolodex in my brain spun and, amazingly,  I remembered. I did interview him, but didn’t quote him.  Some people take offense to that.  Yes, I did and while I didn’t quote you in the story, our conversation helped me get a better grip on the topic. A stock answer but true.

 More here on the HVMA program:

In 2008, Harvard Vanguard began offering “shared medical appointments,” or SMAs. They’re not classes, emphasizes internist Gretchen Gaida. SMAs are scheduled for physicals, well-child checkups, chronic illness management and other types of primary care, as well as for specialty care. Six to 14 patients, who sign agreements to keep information about the others confidential, participate. SMAs last 1½ hours, but patients can leave when they feel their questions have been answered. Doctors take blood pressures and listen to hearts in front of the room but examine patients in a private room when necessary.

Graduate: MIT Infant Cognition Lab

Physicians bill the same for patients seen in an SMA or individually. Considering doctors might schedule only four individual patient visits in 90 minutes, Gaida says, income from SMAs enables Harvard Vanguard to pay for the extra health professionals needed to run them smoothly.

 Finally, since I’m in rare, chitty-chatty first person mode, check out my post on Nature Network Boston about how that same baby may have been caught up in the Harvard psych research scandal.

Something about Mark Hauser’s now questionable research sounded familiar to me. Then I read that he worked with Harvard researcher Elizabeth Spelke.

Turns out I enrolled my infant son (now 12) in one of her experiments. And the study that appears to be based on the data includes Hauser as a co-author.  

 

Health care summit streaming live

Health care summit streaming live via the excellent Association of Health Care Journalists.  Or from The White House.  (11:45 Both appear to be down and the moment.)

For live blogging: a view from the right at the Cato Institute and a view from the left at the Daily Kos.

Also, it is worth noting that health care reform marches on in Massachusetts without action in Congress.

See the Globe’s story today about one group of doctors sending  most of their patients to a hospital willing to coordiate care with primary care docs. (Disclosure: I am a Harvard Vanguard patient.)

Harvard Vanguard Medical Associates said it has started sending many of its Boston patients to Beth Israel Deaconess Medical Center, unless the patients have a prior relationship with a doctor at the Brigham, where Harvard Vanguard doctors have referred nearly 100 percent of Boston patients for years.

Dr. Gene Lindsey – chief executive of Harvard Vanguard’s parent organization, Atrius Health – said he felt the organization could better coordinate care at Beth Israel Deaconess, partly because the hospital has agreed to send patients back to their primary care doctor or a specialist at Harvard Vanguard after their inpatient stay, rather than keep them in the more expensive hospital system.

Atrius, which has more than 800 doctors, is also shifting many of its new orthopedic referrals to New England Baptist Hospital from Faulkner Hospital, which is part of the Brigham. Atrius doctors did 1,000 procedures at the Baptist last year; Lindsey said he expects that number to double this year, a move driven in part by the Baptist’s success at reducing surgical infections.

There is also a substory here about the expansion of digital health care.  Read here from John Halamka’s blog. 

Health plans milk college students

The state has issued a new report documenting yet another way college students get nickle and dimed – on health insurance. The message here — stay on your parents plan.

Here a link to a PPT on the actual study.  

This from the Globe story:

Insurance companies rack up much higher profits on health coverage sold to nearly 100,000 Massachusetts college students than on plans available to the general public, according to long-awaited data released late yesterday by the state. The figures also show that college-student plans also have higher administrative costs…

The state plans to ”study whether the Connector Authority, the agency that oversees the state’s landmark health insurance law, could create a better product for the student market.”

Isn’t that something the universities should be doing?

 

Insured and bankrupt + CRP tests

“Underinsurance is the great hidden risk of the American health care system,” said Elizabeth Warren, a Harvard law professor who has analyzed medical bankruptcies. “People do not realize they are one diagnosis away from financial collapse.”

Warren made her comment in today’s New York Times story about how a lot of the health insurance plans out there won’t protect you from catastrophic medical expenses.

For more on this, see:

My story below on last week’s State House hearing on the cost of co-payments in the Mass plan.

Also see comment from Dr. Steffi Woolhandler’s comments on the same topic.

Also, see this Globe story on high copays.

On another topic  Globe reports on an important Boston study about the limits of a new test for heart disease risk.  Screening health people for illnesses is the subject of much debate.

Researchers, led by cardiologists at Massachusetts General Hospital, reported yesterday that testing patients for a protein associated with inflammation may help predict the risk of heart attacks and strokes in certain cases but that it is probably not useful as a widespread, routine screening tool.

The Mass. General research does not directly contradict a landmark study from Brigham and Women’s Hospital last year – which was highly supportive of testing for C-reactive protein – but sounds a more cautious note on expanding its use. It is the latest study in one of cardiology’s hottest areas, which has pitted specialists in a decade-long back and forth over the value of screening patients with the test.

The Times has a story on a related study.

Here’s the Brigham’s take on CRP. (.pdf)  

Health Wonk Review: Bosstown edition

Today, BHN hosts the Health Wonk Review, the floating web digest of health policy blog posts.

Guy Aceto/ Backstreets.com

This is Boston, but we already had a baseball theme. Summer reminds me of growing up on  the Jersey Shore. So, this week — the Boss-town edition. Dedicated to Danny Federici,  Bruce Springsteen’s organ player.  He died of melanoma last year.

 For a round up of recent Boston news,  see my fresh posting on Mass Device.com. I blog weekly for this device industry news site.

The Price You Pay

Healthcare Technology News offers a post on the health industry meeting with President Obama: “What We Call Health Care Costs, They Call Income.” The group’s proposed $2 trillion in reductions in the rate of growth of health care costs. They also pledged to reduce the growth in costs by 1.5% each year for ten years. “It’s not enforceable and there are plenty of reasons to view this cynically,” HTN asks. “But is it a signal that health care reform has a real chance this year?”

Joseph Paduda at Managed Health Matters reports on a health reform meeting sponsored by pharmacy benefits company Medco. Of the dozen meetings and press conferences on health reform each week –“This was one of the better ones I’ve (remotely) attended,” he said.  Why? “Because the conversation was realistic, pointed, and quickly got into the reality of health care reform – it’s about cost.” Special extra: retro anti-health reform graphic featuring Ronald Reagan.

Living Proof?

MedicaidFrontPage takes on reform’s hot topic. In “The Public Plan…Balance is the Key to Life,”  Brady Augustine offers updates, thoughts and links on the debate over the public insurance option. He points out that some some states already have public plans for employees or Medicaid recipients.

At the Health Affairs Blog, Harold Luft  proposes a risk pool as an alternative to the public plan in “Beyond The Public Plan Debate: A Pathway To Transform The Delivery System.”  Luft discusses the “weaknesses of the competing visions for a public plan option.” He outlines his proposed alternative: “a publicly chartered major risk pool that eliminates the need for the problematic behaviors of private health plans while enhancing choices for providers and patients.”

Reason to Believe

Kaiser Family Foundation’s head, Drew Altman, sees big differences in opinion between experts and the public on health care.

 Dave Williams at the Health Business Blog doesn’t think Altman has it quite right. He looks at the Kaiser survey point by point and tells us where he thinks the public stands on issues like HIT, quality and unnecessary care. A post on New Health Dialogue by Joanne Kenen  offers more thought on Altman’s ideas. 

Cadillac Ranch

Julie Ferguson gathers up reports on the potential impact of Chrysler and GM’s bankruptcies on state workers’ comp systems over at Workers’ Comp Insider. For example, she notes that Ohio’s Attorney General Richard Cordray has filed a "limited objection" to the pending sale of Chrysler, claiming the new owner won’t be required to meet workman’s comp obligations. WCI gives a nod to Roberto Ceniceros of Business Insurance for his thorough coverage of the issue.  

 Devil’s Arcade

Photo by Dop Deep

The Health Care Renewal blog offers a post entitled From the “Era of Cyber Hospitals to an Unfinished “Pipe Dream”There, Brown University’s Dr. Roy Poses notes that testimony in the ongoing civil lawsuit against corrupt HealthSouth hospital CEO Richard Scrushy cautions against buying into innovation hype. The “digital hospital” idea HealthSouth trumpeted in 2001 is an empty building. At the trial Scrushy testified that the hospital was a “pipe dream.”

 Dr. Poses digs way back and finds a lot of cheerleading for this failed digital hospital project. “We are constantly bombarded with publicity about the latest health care ‘innovations.’ We are warned, however, that any new regulation of health care corporations may dry up the pipeline of ‘innovations,’ imperiling us all.  Yet how many of these “innovations” actually improve health?” he writes   

 

Are you tough enough to play the game they play? 

Maybe this was an excuse to play video games, but David Porter at the Health Disparities blog explains how researchers are using the World of Warcraft and other “virtual worlds”  to study natural experiments. In this case, he talks about a virtual virus – the kind that attacks player in the game, not the computer.

 For the uninitiated, this involves a using a virus-infected virtual pet to attack the enemy. Porter described it as “an excellent example of a natural experiment and how people may act during a pandemic…” He said researchers analyzed data supplied by the game developer and cites two papers one Epidemiology and another in The Lancet Infectious Diseases.

 

Working on a Dream

Anthony Wright presents Getting to universal… posted at Health Access WeBlog.  He agrees with with the CBO that an individual mandate by itself won’t get us to universal coverage, but disagrees with other supposed barriers to that goal.

 BNET Healthcare asks “Thought Leaders Propose Health Reforms, But Will They Work?”  The authors of New England Journal of Medicine article favor "accountable care organizations" that would enable healthcare providers to improve quality and reduce cost growth.  BNET thinks their view of physicians and the health care business is “too idealistic to offer a practical road map to reform.”

 Colorado Health Insurance Insider reports that the governor has signed Colorado Senate Bill 88 granting dental and health insurance benefits to domestic partners of gay and lesbian state employees.

 

Spare Parts  

The Health Care Blog offers a post by Mark Leavitt, head of Certification Commission for Healthcare Information Technology, or CCHIT. "Certifying Health IT: Let’s Set the (Electronic Health) Record Straight." In this post, Leavitt responds to accusations that CCHIT is too close to the HIT industry to act as a certifying agency. The charges emerged in stories from the The Washington Post, including one entitled “Group Seeks Sway Over E-Records System.” The Post also reported on the dispute. 

 Neil Versel at Healthcare IT Blog comments on an “outrageous statement” by the CEO of Epic Systems “Vendors, this is your wake-up call”

 

 The Big Muddy

Sam Solomon of Canadian Medicine describes a medical crisis triggered by a nuclear accident. “When nuclear nonproliferation is the problem” He describes his post as “an article about the potential consequences, both clinical and political, of the recent shutdown of the nuclear power plant in Ontario that produces about half of the world’s supply of a certain critical radioisotope used in diagnostic imaging exams.”

 In a post entitled Death Form a Thousand Cuts Outside of the Patient Centered Medical Home,  Jaan Sidorov notes “that while health reform may be on the way, there are a surprising number of day to day hassles that are bleeding primary care physicians dry.” From the The Disease Management Care blog

 

Don’t get caught on the wrong side of that line

Mike Feehan at Insureblog contemplates the difference between medical care and health care. “In order to reach meaningful conclusions about the direction of health care reform, we need to understand the relationship of health care to wellness… We can exercise (free). We can get adequate sleep (free). We can steer clear of substance abuse of all kinds (free). We can keep a reasonable diet (free). We can always wash our hands (free). We can hold it down to 85 on the Interstate (free). We can stop smoking or never start (better than free). To a great extent we already have free health care in the U.S.”
  

Better Days

Jason Shafrin at Healthcare Economist notes that Medicare Part D plan was supposed to provide a prescription drug benefit for those who did not have it. The Healthcare Economist reviews a paper that that asked how well the program is working. It found that after the enactment of Medicare Part D,  only 7% of seniors lacked drug coverage, compared to 24% before the launch of Part D.

Glenn Laffel at Pizaazz tell us: “It’s been a long strange trip for Dendreon, the makers of Provenge a new immune therapy for prostate cancer. No one seemed to take the stuff seriously, but now the definitive trial has been completed and lo and behold, it works! No one could be happier than its shareholders.”

Growin’ Up

Philip Zorn presents guest blogger Robert Nelb on Effortless Enrollment Saves Taxpayers $ and Helps Uninsured Children Access Medicaid and CHIP posted at Say Ahhh! A Children’s Health Policy Blog. Nelb talks about a Brookings Institute paper on the need for effortless enrollment in CHIP and Medicaid programs. He makes the case that automatic enrollment would not only save taxpayers money, it could save lives.

 

Spirit in the Night

Find Clearing the Haze – Is Marijuana Addictive?  at Brain Blogger. ”America’s most popular illegal drug has remained largely a scientific mystery. It is a drug that millions of Americans have been using regularly for years, and, from a clinical perspective, it remains the least studied illicit drug of all.”

WSJ rips Mass Connector health plan

Today’s editorial in the conservative Wall Street Journal opinion section rips into the Mass health plan. Their argument is based on the old claim equating government attempts at control costs to rationing.

They also embrace the new party line: cost controls and evidence-based medicine means Big Brother won’t let you get that MRI.

Single payer folks – most on the other end of the political spectrum — don’t like the plan much either. They mostly argue that setting up a quasi-government-run insurance program will work better. See David Himmelstein’s presentation to members of Congress here. 

Read the state’s description of the plan here.

My family’s health insurance comes from a job in a shrinking industry dealing with waves of layoffs.  Cost of the care for Mass plan — and all other plan — are a key concern. But, I get some piece of mind knowing we have the Mass Connector to fall back on, even if it is not perfect and means I have to skip a scan or two.

As far as evidence-based medicine goes, I care what my doctor thinks, but I like the idea that she’s guided by recent research, not just her habits or the last journal article she happened to read.

The business of Partners v. Partners as a group of non-profit teaching hospitals

Consider Monday’s Globe op-ed from Dr. James J. Mongan, CEO of Partners HealthCare, on how to cut costs.

…(W) e are not the only state experiencing healthcare cost increases; this is a national issue, and there are no villains or easy answers to the problem.

v.

A recent Boston Globe series on pricing and Partners: ” A handshake that made healthcare history“

Partners HealthCare was born in 1993, but its powerhouse potential didn’t fully hit home until 2000. That’s when the emerging giant cut a quiet deal with Blue Cross to ratchet up insurance costs across the state. Nothing in Massachusetts healthcare has been the same since.

In trying to figure whether there is contradiction or synergy between these two items, I came across NH-based Kevinmd.com. Kevin Pho, a Nashua blogging doc has his own ideas about the Partners and heatlh care costs.  

I don’t blame Partners for maximizing their revenue. They know that no other city in the country can boast two nationally ranked academic institutions, and take advantage of that fact to bully the insurance companies. It’s smart business.

Those that are unhappy with the situation – insurance companies, competing hospitals, and health policy wonks looking to control health care costs – need to rein in patient demand for their services. Educate the public that community hospitals can provide care equal to, or better than, MGH and the Brigham in routine cases.
 

Taxing health benefits?

The NY Times has a story about the Obama team considering some kind of tax on health benefits.

 The Obama administration is signaling to Congress that the president could support taxing some employee health benefits, as several influential lawmakers and many economists favor, to help pay for overhauling the health care system.

The proposal is politically problematic for President Obama, however, since it is similar to one he denounced in the presidential campaign as “the largest middle-class tax increase in history.” Most Americans with insurance get it from their employers, and taxing workers for the benefit is opposed by union leaders and some businesses.

 The reliable, D.C.-based Alliance for Health Reform tells you all about taxes and health insurance in this primer:

The United States tax system subsidizes the purchase of employer-sponsored health insurance for more than 160 million non-elderly people at a “cost” of approximately $200 billion a year. This tax subsidy is a major reason why most Americans have health insurance coverage through either their own employer or that of a family member. In recent months, the tax treatment of health insurance has gained a lot of attention – both during the presidential campaign and in health reform debates in Congress.

What is the current tax treatment of employer-sponsored health insurance? How does the tax treatment of health insurance impact employers? How does it impact employees? Do some workers benefit more than others from the current tax subsidies? Does altering the tax treatment of health insurance have the potential to expand or diminish coverage? Will cost containment efforts lead policy makers to consider altering the tax treatment of health insurance?

In addition to David Blumenthal of the MGH/Partners Institute for Health Policy, the group  takes note of the following local experts:

Two from Harvard

David Cutler

Professor Cutler served on the Council of Economic Advisers and the National Economic Council during the Clinton Administration and has advised the Presidential campaigns of Bill Bradley, John Kerry, and Barack Obama. Among other affiliations, Professor Cutler has held positions with the National Institutes of Health and the National Academy of Sciences. Currently, Professor Cutler is a Research Associate at the National Bureau of Economic Research and a member of the Institute of Medicine. NYTimes story featuring DC

Katherine Baicker, PhD

Professor of Health Economics in the Department of Health Policy and Management at the Harvard School of Public Health.  She is a research associate at the National Bureau of Economic Research. 

MIT

Jonathan Gruber, Massachusetts Institute of Technology.

Dr. Gruber’s research focuses on the areas of public finance and health economics.