humani nil a me alienum puto

random rants about news, the law, healthcare law, economics and anything I find amusing

Alex Colville – painting just struck me…

via Colville_04.jpg (JPEG Image, 741×560 pixels).

Filed under: Personal Posts, , , ,

Annual Perseid Star Party

Every year since we’ve been at our house we’ve had an annual bonfire and star party.  We get some of the neighbors and our friends together, build a small fire and make some smores.   We do it right around the time of the annual Perseid meteor shower.   We tend to miss the peak by a few days, but we always seem to see a few.   And, as we always do, we got out my two telescopes and showed the neighborhood a few night sky objects.

cocking-jupiter021305This year Jupiter was the only early evening planet visible; but it is my favorite.   (Saturn’s close — but setting too early in the evening this year’s August).  Here’s a photo of how Jupiter looked for us through my Meade ETX 125, courtesy of another amateur using the same scope as I have.   Jupiter is great because the kids (and parents) can immediately identify it.  It was really appropriate this year, the 400th anniversary of Galileo’s first astronomical use of the telescope.  The kids kept asking what the stars were that surrounded Jupiter.  They loved the fact that they were Jupiter’s moons.  They even suffered through me talking about the volcanism of Io, the oceans under the surface ice of Ganymede and Europa and how Galileo confirmed the Copernican world view by asking the same question that they had.

OO_08_Oct_26_53

Even with the city lights, we were able to get a few deep sky sights in scope.  After a little star hopping (aided by a new friend to our family – Tom – a geek like me who likes amateur astronomy), we were able to get the great Hercules cluster in my larger 8″ home built dobsonian scope.   The cluster (M13) is a globular cluster with about 200,000 stars sitting in the halo of our Milky Way Galaxy.  In the scope it looks like a dandelion fluff.  Impressive when you think that it contains that many stars — but a bit less identifiable than Jupiter.  Here’s what it looks like in a scope like mine after a few minutes exposure.  As I said, in my scope, with city lights and lower magnification — more of a smudge.

m39_noao_bigI was also able to get M39, an open cluster, in my larger scope.  Unfortunately, by the time I got it in focus, most of our guests had taken off.  I wish I had gotten it in view earlier, because it probably would have gotten more of a response than the Hercules cluster.  The stars in the open cluster are gorgeous in the scope, almost like jewels.  Here’s  a picture of them through a much larger telescope — certainly not what they look like through mine — but it very much catches the effect.  DSC_1850

Most important to me, my kids got a kick out the the evening.  They didn’t last that long — my youngest was going to bed only just after sun set.  Noelle got to see most of the sites.  And, of course, she had her fair share of smores.  I’m already looking forward to next year.

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Another View – Get Rid of Comprehensive Healthcare Insurance?

Thanks to Paul Levy’s Running a Hospital blog for putting me onto this article.  I started reading this too late but could not pull myself away from it.

If you are pondering health care reform this season, “How American Health Care Killed My Father” by David Goldhill should be something you read.  He’s an outsider to health care finance and delivery and a consumer that has had the healthcare system profoundly (and negatively) affect his family.

With this personal interest, he’s become quite focused on the question: how can a technically advanced, high cost, reputable, New York area hospital with caring, highly educated and highly skilled physicians and nurses allow his father to die from a facility acquired infection avoidable (probably) by adequate hand-washing protocols?  The experience has led him to an “obsession with [the] health-care system” and to start asking how could it possibly be structured the way that it is.   With this background, he asks whether today’s proposed reforms actually fix what he understands to be wrong with the American health care system?  His conclusion is no:

The most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers—by bringing greater transparency and competition to the health-care industry, and by directly subsidizing those who can’t afford care—we’d find that consumers could buy much more of their care directly than we might initially think, and that over time we’d see better care and better service, at lower cost, as a result.

A more consumer-centered health-care system would not rely on a single form of financing for health-care purchases; it would make use of different sorts of financing for different elements of care—with routine care funded largely out of our incomes; major, predictable expenses (including much end-of-life care) funded by savings and credit; and massive, unpredictable expenses funded by insurance.

I take issue with some of what he writes, particularly about hospitals.  Nonetheless, it is worth a read and some serious thought, whether you agree or not with all of his statements, conclusions and his solution.

via How American Health Care Killed My Father – The Atlantic (September 2009).

Filed under: Health Law, Reform, , , ,

H1N1, CDC, CMS and EMTALA

In a follow-up to previous posts (here, here) on H1N1, I’m catching up on reading from this week and I must have missed the White House’s report on possible effects of a resurgence of the swine flu pandemic this fall and winter.   I read through the report and it is eye opening, although not as dire as some possible scenarios presented by at least some for a pandemic avian flu.  According to the White House advisory panel report a possible scenario would:

•produce infection of 30–50% of the U.S. population this fall and winter, with symptoms in approximately 20–40% of the population (60–120 million people), more than half of whom would seek medical attention.
•lead to as many as 1.8 million U.S. hospital admissions during the epidemic, with up to 300,000 patients requiring care in intensive care units (ICUs). Importantly, these very ill patients could occupy 50–100 percent of all ICU beds in affected regions of the country at the peak of the epidemic and could place enormous stress on ICU units, which normally operate close to capacity.
•cause between 30,000 and 90,000 deaths in the United States, concentrated among children
and young adults. In contrast, the 30,000–40,000 annual deaths typically associated with seasonal flu in the United States occur mainly among people over 65. As a result, 2009-H1N1 would lead to many more years of life lost.
•pose especially high risks for individuals with certain pre-existing conditions, including pregnant women and patients with neurological disorders or respiratory impairment, diabetes, or severe obesity and possibly for certain populations, such as Native Americans.

The NY Times later reported that the CDC had indicated that this was not a “likely scenario,” which may be reassuring.

Also of note, The Centers for Medicare & Medicaid Services  issued a memo and fact sheet clarifying permissible options under the Emergency Medical Treatment and Labor Act for hospitals handling a surge in patients with swine flu.  The fact sheet discusses options for hospitals experiencing surges with and without a declared ‘waiver’ of EMTALA (requiring presidential emergency declaration and certain other actions), including out of department medical screening exams and off-campus flu screening centers.

PCAST_H1N1_Report.pdf (application/pdf Object).

Filed under: Health Law, Public Health, , , ,

potpourri podcasts & links

A few noteworthy podcasts/links of the week:

Diane Rehm Show.  On Thursday, hosted Jill Tarter, Director of the Search for Extraterrestrial Intelligence Institute’s Center for SETI Research.  Jill Tarter also has a neat little presentation when she recently received the TED prize.  I’ve posted on TED talks before.  Discussion around SETI @ 50 years!

Diane Rehm Show.  On Wednesday, hosted Maxwell Mehlman, professor of law and bioethics at Case Western Reserve University and the author of “Wondergenes”; “The Encyclopedia of Ethical, Legal, and Policy Issues in Biotechnology”; and “Access to the Genome” and one of my old professors.  The conversation is about his recent book, Price of Perfection.

The Lost Decade.  What’s been the economic growth rate over 1999 – 2009 and how does it compare to others during the modern post-War period.  Ouch.

Co-Ops.  What are they and are they a bridge to bipartisan healthcare reform?

Recession bottoming out?  One of the two steel blast furnaces in Cleveland are finally firing up again.  “[W]e are restarting C-5 blast furnace, a steel shop, hot mill, pickle line, tandem mill and galvanizing line at ArcelorMittal Cleveland…However, we do not expect demand to return to the levels seen in 2008 for sometime yet and remain cautiously optimistic for a low and progressive recovery.”  When both furnaces were turned off (I think late last year), it was a signal of the unusual depth of this ‘Great Recession.’  I’ve been watching to see when they’d fire up again.  This is a good sign.

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Healthcare Economic – Supply/Demand Side Goals to Reform

Over the years Uwe E. Reinhardt has written, lectured and testified extensively on health care economics, alternative health care financing and delivery systems (e.g., here and here) and health care financing and delivery reform in the United States.  He’s one of those guys I recall studying back in undergraduate health care economics classes (who can forget a name like Uwe).

In a recent NYT Economix blog post he provides succinct economics supply side/demand side breakdown of what the general economic goals are for health care financing and delivery reform as currently evisioned.  I thought was a useful way of looking at the (rational) parts of the current debate.   I emphatically take no position on health care reform policy initiatives, but in light of so much of the rather less than civil polemics I see around the policy debate, this seems a return to basic analytics of what might be accomplished through reform.

1. Financial barriers should not stand between Americans and preventive or acute health care that they sincerely believe will address concerns over a troubling medical condition, in a timely manner, before that condition grows into a critically serious illness.

2. Having received needed health care, no American family should be so financially devastated by medical bills that it cannot meet routine daily living expenses — for example, make utility or mortgage payments on time or finance the education of the family’s children.

3. The future growth in national health spending should be constrained to fall significantly below currently projected spending growth, which has the United States devoting about 40 percent of its G.D.P. to health care by midcentury.All other goals are subordinate to these three overarching goals, as are the means to reach them.

He breaks it down into into one slide — which I think, again, fairly succinctly states the targeted supply/demand side areas:

I found it natural to categorize these components into those aimed mainly at reforming the demand side of the health sector, those aimed mainly at the supply side, and those cutting across both sides — e.g., payment reform and overall cost control.health care delivery

He then discusses the time frame for reform.   He feels with good reason that the supply side fix (top left box), while incredibly challenging, would be achievable through current legislation.   He indicates, however, that it would not be particularly successful unless certain core requirements are met to address the adverse selection/moral hazard problems inherent in the fix.

He notes, however, that the right box and the cross-cutting payment reform (bottom boxes) can only be accomplished over a much extended period due to their complexity, lack of current infrastructure (e.g., systemic and cross-functional EHR systems, solid quality measurement systems, systems whereby health care providers can assume and manage financial risk for populations) and a public policy and business driven process of how to actually move from FFS systems to some form of bundled payment or capitation.

If 1) either private or public health insurers must accept all comers and may not base premiums on the applicant’s health status, then 2)  individuals must be mandated to purchase at least a basic package of health insurance, lest they freeload on the system. Such a mandate, in turn, requires that 3) families be publicly subsidized to make the cost of that basic package affordable to them. A sound reform of the health insurance market cannot have just two of these features. It must have all three.

****

Designing and implementing the rest of the reform agenda in the chart — reforming the supply side, payment reform and cost control — is a much longer-run effort that may take an entire decade or more. It is more challenging than was landing a man on the moon, as no moneyed lunar interest groups sought to prevent man’s visit there.

The delema should be obvious.  Given Dr. Reinhardt’s core requirements for supply side reform, the ability to subsidize #1 (preventative intervention) and #2 (insurance against catostrophic financial loss due to illness) universally is going to be extraordinarily costly to public fisc.  Without management of #3 (which isn’t going to come without significant challenge) the money must come from somewhere.  And, of course, if #3 is not achievable for some unspecified extended period, gap financing is necessary.   Richard Posner recently has a post on just this point.

Filed under: Health Law, Personal Posts, Reform, , , ,

Brooks contemplates a speculative fiction theme… What if there were no posterity?

I tend to like it when David Brooks meanders away from the politics of present takes a little cerebral detour through a philosophical tangent.  From his most recent:

“What would happen if a freak solar event sterilized the people on the half of the earth that happened to be facing the sun? If you take an individualistic view of the world, not much would happen immediately….But, of course, we don’t lead individualistic lives. Material conditions do not drive history. People live in a compact between the dead, the living and the unborn, and the value of the thought experiment is that it reminds us of the power posterity holds over our lives…Without posterity, there are no grand designs. There are no high ambitions. Politics becomes insignificant. Even words like justice lose meaning because everything gets reduced to the narrow qualities of the here and now… The scenario is unrelievedly grim. An individual who does not have children still contributes fully to the future of society. But when a society doesn’t reproduce there is nothing left to contribute to… But, of course, …[t]here are no sterilizing sunspots. Instead, we are blessed with the disciplining power of our posterity. We rely on this strong, invisible and unacknowledged force — these millions of unborn people we will never meet but who give us the gift of our way of life.”

Brooks attributes his thoughts on this to a blog he follows, Marginal Revolution.  Never heard of, but I’ve subscribed to see if they are as erudite as Brooks says. (Impress, guys, or I’ll dump you like week old kung po chicken in my fridge.  Too much to read already).

This is, of course, not a totally novel thought experiment.  See, for example, the novels Children of Men and the The Handmaiden’s Tale.  (I recommend, of course, the books over the movies, but whatever you like; Children of Men is not a bad movie, but deviates significantly from the novel).   These works contemplate either universal unexplained sterilizationor at least wide-spread infertility, in the case of The Handmaiden’s Tale.  They work equally well as fictional counterparts to Brook’s essay.  They are profoundly sad worlds.

I think, however, a scenario that would affect only a specific widespread geography (e.g., half the earth) would be the more interesting exploration for a work of speculative fiction.  Anyway, foder for someone’s next science fiction story or composition on the nature, and need, of human posterity.

Filed under: Personal Posts

Remembering Apollo 11 – The Big Picture

The Boston Globe’s big picture does it again with some amazing photographs remembering the Apollo 11 mission.  Take a look.  The one photo (Earth-rise) was on my wall in my bedroom growing up.  Gorgeous.

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Health Policy Pro/Con Summary of a “Public Plan”

I was catching up on reading and spotted this pretty good (and pretty short) summary from Health Affairs of some of the pro/con arguments concerning a publicly administered health insurance option as part of health care reform.  It’s worth a read and I think fairly and intelligently gives a high level summary of the debate.

For another view of the public plan option, which argues that a public plan option is necessary due to significant consolidation in the health insurance and hospital markets, see the Urban Institute’s paper entitled Is the Public Plan Option a Necessary Part of Health Reform? http://www.urban.org/UploadedPDF/411915_public_plan_option.pdf This is one of the prominent arguments that I have heard the Obama administration make. This might seem a paradoxical argument — i.e., you need direct government participation in the insurance market to make it more competitive.   Query, given this line of argument and whatever else occurs, if it forbodes future antitrust enforcement in the healthcare insurance and delivery sectors.

PostScript 7/27/2009:  Saw this Modern Healthcare discussion of healthcare antitrust enforcement giving some additional color on how healthcare reform and antitrust enforcement may tie together.

Filed under: Health Law, Reform, , ,

Rights to the Bits and Bytes in Your EHR

Back in 2001, right before the HIPAA privacy rules took effect, I wrote a law school student note entitled “The Emergence of the Health Care Information Trust.”  Pretty heady, and perhaps a bit Pollyanna-ish, stuff.  In the note I argued that to pull the hidden value of disparate health care information out of the islands of digital data that had been forming throughout the health care system, some form of clearing house for patients, with strong fiduciary obligation to individual patients participants, needed to emerge.  In fact, because of HIPAA’s soon to be finalized privacy regulations, without patients expressly vesting rights in something like a health care data aggregator,  it would be very difficult (if not impossible) to use the information commercially for purposes other than directly for healthcare treatment, payment, operations and certain research.  Further, the value in that data would not be able to accrue to the individual any other way.  My concept was to allow use of patient data, with defined limitations set by the patient, with micropayments to patients for such patient approved use by anyone seeking to access the aggregated data.

Anyway, the eight years since I wrote the article, I am not sure where the health care data market is going.  But there are some services that seem to be starting to emerge as potential aggregators.  Most notably, both Microsoft and Google have been taking initiatives in the area.  Of course, Microsoft and Google are not what I had projected; but it probably makes more sense in hindsight that the two biggest IT juggernaughts would be making headways into this this very young market with unknown potential.  If anything, the ability to pull good, useful and linkable health care information (except maybe healthcare claims data) is a monumental problem, and true electronic medical records are, at best, still in their infancy.  So, also, the immediate possibilities of wide-scale transfers to such aggregators.

One of the obvious limitations, even if and when health record data is transferable without impossibly difficult transactional barriers and costs, is the fact that the privacy regulations are really set up to address patient rights in principally paper records.   So, even if you wished to transmit electronic data to an aggregator service (be it my concept of a Healthcare Information Trust or, for that matter, Google or Microsoft), there are no express provisions addressing this.

So I found it interesting when I read about “A Declaration of Health Data Rights.”  In it, the organization specifically makes mention to access to records in “computable form.”  Also, in reading about the initiative in the NYT’s Bits blog, I took particular note that both Microsoft and Google have a role in it.  Ah, this makes some sense now.

For what its worth, the group desires:

A Declaration of Health Data Rights

In an era when technology allows personal health information to be more easily stored, updated, accessed and exchanged, the following rights should be self-evident and inalienable. We the people:

1. Have the right to our own health data

2. Have the right to know the source of each health data element

3. Have the right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; if data exist in computable form, they must be made available in that form

4. Have the right to share our health data with others as we see fit

These principles express basic human rights as well as essential elements of health care that is participatory, appropriate and in the interests of each patient. No law or policy should abridge these rights.

via HealthDataRights.org.

Filed under: Health Law, HIPAA, , , ,

No Country for the Public Plan Option

In today’s The Health Care Blog, Jeff Goldsmith provides remarks in an article entitle No Country for Old Men, which, perhaps, should be called “No Country for the Public Plan Option.”  An interesting read with some observations about the systemic risks for a public plan option and the challenges its proposal presents to political success for healthcare reform this time around.  After significant discussion, Mr. Goldsmith concludes “[r]ather than wasting scarce political capital on the public plan, health reformers need to focus on hospital and primary care physician payment reform, expanding Medicare coverage for the almost 11 million uninsured boomers and sensible design of a federal health insurance exchange.   It isn’t going to take a miracle to get this important public task done, just focus and discipline.” The Health Care Blog: No Country for Old Men.

Filed under: Health Law, Payment, Reform, ,

Recent scenes from the ISS – The Big Picture – Boston.com

Bad Astronomer frequently links to The Boston Globe’s period “The Big Picture Show.”  These pictures are breathtaking and take a look.  All are from taken from the International Space Station and show an eruption of Sarychev Peak Volcano (spectacular), the waning gibbous moon through the Earth’s atmosphere, Mt. Fuji and other amazing shots.  Note that most of the detail shots also have a googlemaps link.  Recent scenes from the ISS – The Big Picture – Boston.com.  Here’s a lower resolution of the eruption:

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Reform Moves Stir Talk of Bundled Payments | BNET Healthcare Blog | BNET

A BNet article, Reform Moves Stir Talk of Bundled Payments, discusses healthcare reformers’ conceptualizing bundling payments to align physician and health system/hospital outcome interests.  The article has a number of cites to other reports, discussions and administration statements.  It also points out what I find facinating about the trend — what did not occur in the 1990s may be coming through healthcare payment reform today.   But are today’s integrated delivery systems (and the regulatory environment) prepared for risk in any format other than PPS payments?

All of this reminds some observers of the rapid formation of integrated delivery systems during the ‘90s, when many hospitals and physicians were circling the wagons to fend off the expected onslaught of capitated managed care plans. That never materialized in most places, but many systems retained all or some of their employed primary-care physicians. Now, partly in expectation of healthcare reform, they’re also stepping up their hiring of specialists.

“The handwriting is on the wall,” Bill Jessee, MD, president and CEO of the Medical Group Management Association, tells BNET. “The push is going to be towards more integration of physicians, hospitals, home health, and other services. And Medicare or a private insurer may put the provider at risk, instead of the insurer being at risk. It’s not explicit, but it’s implicit in a lot of the reform discussions that that’s the direction they’d like to move. The bundled payment demonstrations are a manifestation of that.”

via Reform Moves Stir Talk of Bundled Payments | BNET Healthcare Blog | BNET.

Filed under: Comparative Effectiveness Rearch, Health Law, Payment, Reform, , , ,

Who are the Uninsured?

Back in 2005, I co-authored an article with Richard Stuhan, a partner at Jones Day.  The article was primarily about the concerted and misguided  efforts to sue non-profit hospitals for their alleged failure to provide charity care.  The plaintiffs contended that such provision of charity care was a legal obligations of 501(c)(3) tax exempt entities.   These suits, while striking the public policy cord concerning the plight of the uninsured and the inflation of health care costs and charges, were based upon ill conceived legal theories and, accordingly,  failed miserably.  But they probably were a precursor of congressional interest in charity care provided by non-profit hospitals and health systems — which is currently playing out and has resulted in some significant changes, most notably the new Form 990s.

One of the items we briefly discussed in that article, an issue that should be a major large part of the health care reform debate, is the scope of the health care insurance (or, more particularly, uninsured) problem in the United States.  Who accounts for the uninsured figures and why are they uninsured is critical to forming the debate about solutions.  The debate, I would think, is fundamentally different if a substantial portion of the uninsured could afford insurance or could access other forms of insurance (SCHIP, Medicaid, etc.), but decide for personal reasons not to obtain insurance or face administrative, educational or transactional barriers to signing-up for federal or state-sponsored insurance programs for which they would otherwise be eligible.   Circa 2003, the uninsured level was approximately 45 million, but a very significant portion of this populations was either eligible for federal or state programs or were from households that were significantly above the federal poverty level and could, technically, afford insurance.

Periodically, this issue has popped up with one study or another discussing the scope of the uninsured problem — addressing who are they, why are they not insured.   Of course, with this new round of health care reform, the issue of the uninsured should be front in center in the debate.  Recently, a report was issued entitled WHO ARE THE UNINSURED? An Analysis of the Characteristics of Americans Without Health Insurance by the Employment Policies Institute.   This seems to be a fairly politicized organization that has written studies before that have been scorned by some.   So, with that disclaimer and taking the study with a grain of salt, its conclusions are still notable. Assuming its numbers are correct, approximately 43% of the 2006 18-64 year-old uninsured are in households at greater than 2.5x the federal poverty limit.  This is not inconsistent with previous studies I had seen and I would think could be fact checked.

By no means does this take away from the significant and troubling 47% who are involuntarily uninsured.   But the number of individuals and households that have the means to, but choose not to, purchase health care insurance is important to the current debate.  What impact does this very significant portion of the uninsured have for risks of adverse selection, individual/employer mandatory coverage requirements, the level FPL subsidies and other components of healthcare reform bills being proposed.

Filed under: Health Law, Reform, , , , ,

World Bank and H1N1 Economic Forecast

In a follow-up to one of my prior posts (Birds or Pigs?; Pigs Have It), I spotted (thanks to the WSJ Health Blog and Bloomberg) that the The World Bank issued a recent report on the global recovery, entitled Global Development Finance: Charting a Global Recovery.  In it it discusses the potential impact of H1N1 on economic recovery, estimating that by next season the impact of H1N1 is likely to be at least as severe as the Hong Kong Flue of 1968-69.  It also cites other studies to give a range of potential impact on world-wide GNP between 0.7% and 4.8%.   The impact on Mexico, where H1N1 has had a severe effect on tourism and has shut down large sectors of its economy at the start of (or at least the realization of) the outbreak, has been severe.  Estimates are a second quarter 2009 decrease in that country’s output by appoximately 2.2%.

Simulations of the potential economic and human costs of a global pandemic undertaken for the 2006 Global Development Finance report in the context of avian influenza (Burns, van der Mensbrugghe, and Timmer 2006, 2008) suggest that the costs of a global influenza pandemic could range from 0.7 to 4.8 percent of global GDP depending on the severity of the outbreak. The lower estimate is based on the Hong Kong flu of 1968–69, while the upper bound was benchmarked on the 1918–19 Spanish flu. In the case of a serious flu, 70 percent of the overall economic cost would come from absenteeism and efforts to avoid infection. Generally speaking, developing countries would be hardest hit, because higher population densities, relatively weak health care systems, and poverty accentuate the economic impacts in some countries.

Filed under: Health Law, Personal Posts, Public Health, , , ,

Autopsies of War Dead Reveal Ways to Save Others – NYTimes.com

An interesting article in the NYT about CT scans of our departed troops.  The use of the data has led to practical applications.  For example, after noting that tubing to inflate collapsed lungs was not long enough due to the larger size of many of the troops, new protocol were adopted for longer tubes – perhaps saving lives.  Of course, also, better information on armor for troops may have saved lives.

This reminds me of a puzzler on one of the Car Talk shows on NPR (if you are uninitiated, take a listen, Tom & Ray have a lot of fun, but they know there stuff).   The puzzler is about British bombers in WWII and engineering decisions concerning how to armor their undersides in face of anti-aircraft fire.  Quite similar in a way, despite the application in an entirely different war.

Autopsies of War Dead Reveal Ways to Save Others – NYTimes.com.

Filed under: Personal Posts,

Variations in Healthcare Spending – Anchor-Tenant Theory and Fraud and Abuse?

The New Yorker recently had a very interesting expose discussing one of the fundamental economic challenges of healthcare reform.  (Gawande, Atul, The Cost Conundrum: What a Texas town can teach us about health care, June 1, 2009).  Peter Orszag gave a presentation last year at the American Health Lawyers meeting in San Franscisco that I was able to hear.  Mr. Orszag, President Obama’s budget director and formerly head of the Congressional Budget Office, has observed repeatedly (and is quoted in this article as saying) that “[n]early thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas.”  He, and many healthcare economists’ observe, that there is a tremendous amount of variation in healthcare spending throughout various regions of the country that simply cannot be explained after controling for demographics, illness indexes/cases mixes, cost indexes and other similar factors.  And, most importantly, outcomes are no better in higher spending areas.

This New Yorker article paints a narrative story surrounding this frequent observations by looking at case of McAllen, Texas.  McAllen has the particular notoriety of having the highest per capital Medicare spending in the nation.   I think it is an important read for healthcare counsel because of some of the author’s tangential commentary linking McAllen’s higher per capita spending with a culture that could have support higher incidents of fraud and abuse.

According to the article, McAllen spends (using 2006 data) approximately $15,000 per Medicare enrollee.  This is more than twice of what El Paso, Texas, with very similar demographics and population factors, pays.  It is also more than twice what the region surrounding the Mayo Clinic spends.  Ironically, the per capital Medicare spending is more than McAllen’s per capita income.

The New Yorker author discusses this fact with some local physicians who have no idea of this distinction for their community:

One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.  Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person. “Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.  Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said. “It’s malpractice,” a family physician who had practiced here for thirty-three years said. “McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere. That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down? “Practically to zero,” the cardiologist admitted. “Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.  The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”

via Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker.

What is the basis for the higher per capita Medicare spending?

To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice, which has three decades of expertise in examining regional patterns in Medicare payment data. I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.  The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits.

The author discusses the high utilization and costs with various hospital executives, who, like the physicians interviewed, also do not know that McAllen is the most expensive place in the country for Medicare beneficiaries.  The executives of the hospitals, to the author’s belief, authentically did not know their peculiar notariety and, not even recognizing it as an issue, had no truly thoughtful responses as to why it might be.

Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How [are the hospital executives] to know whether all that is essential, let alone the best possible treatment for the patient? It isn’t what they are responsible or accountable for.  Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.

The article suggests, with only a little explanation, that the variation between communities such as McAllen and, in contrast, El Paso or other lower cost regions (with at least the same if not better quality institutions) might be due to an  “anchor tenant theory of economic development.”  Certain markets develop their own economic character, similar to how a mall may be defined by its anchor tenant.  So, the theory goes, certain “anchor tenants” in a market may allow, for example, the development of regional specialization (e.g., biotechnology development in certain cities – Boston, San Franscisco and not in others with similar apparent resources).   Twisting this model a bit, the author posits that the entrepenurial focus of physician medicine in McAllen, changing from the 1990s to present, may be a significant part of the increase in costs.  McAllen was near the median in per capita spending a decade ago.  Importantly, the author then goes on to point out anecdotal evidence of some serious antikickback statute violations — solicitation by certain unnamed physicians of medical directorships in exchange for referrals to hospitals and home health agencies.

This linkage — which is not well developed by the author — is nonetheless a beware moment.   If higher per capita Medicare spending is linked by government enforcement agencies as a proxy for potential higher rates of fraud and abuse behavior, one might see a new horizon for focusing fraud enforcement .  Perhaps this is a stretch – but an interesting linkage is being made here by the author.  It is all the more important due to the prestige of the publication and that the fundamentals of this story find their genesis in the economic theory of healthcare inflation that is the focus of leaders within the current administration.

The author goes on to make a fairly classical example of the challenges of asymetical information in healthcare coupled with the fee-for-service basis of physician payments:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

The author aruges that changing the payor (i.e., government plan competitor, single payor system) will not change this problem.  Even putting the consumer on the hook through medical savings accounts or high deductible plans won’t solve it (if a physician recommends a cardiac bypass, is the patient going to negotiate with the cardiologist, radiologist, anesthesiologist, cardiothoracic surgeon and hospital over expense or the scope of the procedure?).

Then the author suggest that only flipping the economic model might fix this.  The author isn’t quite specific in how this might be accomplished, although he goes to length to contrast the McAllen “anchor-tenant” model with other “anchor-tenant” models of healthcare (e.g., Mayo), suggesting this is the crux of the problem – what kind of medical care provision culture the United States will be developing based upon the economic incentives that are established by insurance payor systems we perpetuate or change through reform.  Not by who cuts the check.

This is worth the read because it sets a story narrative for the harder data Mr. Orszag and others have frequently discussed as healthcare reform is debated.

Filed under: AKS, Comparative Effectiveness Rearch, Health Law, Reform, , , , ,

Effect of Exposure to Small Pharmaceutical Promotional Items on Treatment Preferences, May 11, 2009, Grande et al. 169 (9): 887

A new study finds that subtle exposure to branded pharmaceutical items, even without the social interactions of gifting, influence medical school student attitudes towards brands.  The study has some interesting discussion regarding “boomerang” response by some of the students from the institution that had strong rules prohibiting gifts.  This reaction may have some bearing on current efforts to ban gifts and marketing materials at healthcare institutions as well as the so-called “Sunshine Laws” at the federal and state levels regarding transparency of pharma and medical device marketing and financial arrangements, including gifting.

From the study’s commentary:

Our study finds that subtle exposures to branded pharmaceutical promotional items influences implicit attitudes of medical students toward pharmaceutical brands. The observed effect was modified by training year and school. Among third-year medical students, no significant experimental effects were observed. However, among fourth-year medical students there were significant effects at both schools in our study. Students at Miami responded as we hypothesized, shifting their preferences in the direction of the branding exposure (ie, Lipitor). However, students at Penn had a boomerang response, ie, a behavioral response opposite of the implied marketing intent.22 The most likely explanation for the difference across class year is that, as students advance in their training, they begin to form attitudes toward various treatment options that can be primed with branded promotional items. In comparison to third-year students, fourth-year students have had greater clinical experience and greater exposure to their clinical teachers and prevailing institutional practices.

The divergent effects at our 2 study schools are an interesting finding. At Penn, exposure to the branded items produced less favorable implicit attitudes. One potential explanation for this effect is that the strong school policy provided an external warning about specific persuasion tactics underlying pharmaceutical marketing. This information may have motivated some form of resistance by the audience23 that could have taken the form of simple message rejection or active counterarguing or careful message scrutiny.24 The policy therefore may have heightened the ability of the Penn students to exercise what has been termed “persuasion coping effectiveness”,25 which produces a goal within oneself to achieve one’s own current learning or attitudinal goal independently of what the marketer seems to be trying to accomplish. The differential attitudes observed in the marketing survey, with the Penn students exhibiting significantly more negative attitudes than those in the national sample or for the Miami students where no policy exists, support this explanation. At Miami, where students had more positive attitudes toward marketing, exposure to a branded promotional item likely primed more positive implicit associations.

via Arch Intern Med — Effect of Exposure to Small Pharmaceutical Promotional Items on Treatment Preferences, May 11, 2009, Grande et al. 169 (9): 887.

Filed under: Conflicts of Interest, Health Law, , , ,

Sunshine in Vermont… Again. Vermont Senate Bill (S-048)

As reported in the NY Times Blog yesterday, the State of Vermont, which already had fairly strict provider financial arrangement reporting requirements for pharmaceutical companies doing business in the state, is slated to significantly limit gifts to providers by both pharmaceutical and medical device companies.  The new law, which, according to the NYT blog, will be signed by the governor, will prohibit all but certain enumerated gifts, revise reporting requirements by pharmaceutical companies and expand the reporting requirements to medical device manufactures.

The legislative bodies findings and intent, obviously influenced by the reporting thus far provided under the previous version of the law, outline its concerns, stating its belief that marketing practices can influence the rise in health care spending and that “state of Vermont has a substantial interest in cost containment and the protection of public health.” The legislature cites a number of findings leading to its adoption of the legislation:  (i) an IOM study linking gifts to prescribing behavior, (ii) recent federal crackdowns on medical device manufacturers’ alleged antikickback  violations (see my related post on the federal Sunshine Act), (iii) significant spending in the relatively small state of Vermont on pharma marketing (“[i]n fiscal year 2008, pharmaceutical manufacturers reported spending $2,935,248.00 in Vermont on fees, travel expenses, and other direct payments to Vermont physicians, hospitals, universities, and others”), (iv) the pharma industry’s focus on 100 physician opinion leaders for almost two-thirds of pharma’s spend (“approximately $2.1 million in payments went to physicians…[with the] top 100 individual recipients received nearly $1,770,000.00 in fiscal year 2008”) and prevalence of pharma’s spend throughout Vermont’s 4,573 licensed health care professionals, with 2,280 being recipients.   Based upon the legislation, the Vermont lawmakers certainly are frowning on the nearly $1M spent on food, noting that many food recipients received $1,000 or more spent on them.  One individual recipient, in fact, apparently receive over $15,000 in food.

The legislature concludes that the “act is necessary to increase transparency for consumers by requiring disclosure of allowable expenditures and gifts to health care providers and facilities providing health care [in order] to reduce real or perceived conflicts of interest which undermine patient confidence in health care providers and increase health care costs by influencing prescribing patterns.  Limitations on gifts and increased transparency are expected to save money for consumers, businesses, and the state by reducing the promotion of expensive prescription drugs, biological products, and medical devices, and to protect public health by reducing sales-oriented information to prescribers.”

The new law prohibits “any manufacturer of a prescribed product or any wholesale distributor of medical devices, or any agent thereof, to offer or give any gift to a health care provider.”  It provides that the  attorney general “may bring an action in Washington superior court for injunctive relief, costs, and attorney’s fees and may impose on a manufacturer that violates this section a civil penalty of no more than $10,000.00 per violation. Each unlawful gift shall constitute a separate violation.”

Permitted items that are not deemed prohibited gifts include:  (i) samples, (ii) limited short term evaluation use loaners of medical devices not exceeding 90 days, (iii) reasonable quantities of medical device demonstration or evaluation units to a health care provider to assess the appropriate use and function of the product, (iv) provision, distribution, dissemination, or receipt of peer-reviewed academic, scientific, or clinical articles or journals and other items that serve a genuine educational function, (v) scholarship or other support for medical students, residents, and fellows to attend a significant educational, scientific, or policy-making conference or seminar of a national, regional, or specialty medical or other professional association if the recipient of the scholarship or other support is selected by the association, (vi) rebates and discounts for prescribed products provided in the normal course of business.  Certain items are not prohibited and are considered “allowable expenditures.”  These include (i) certain limited sponsorship of a significant educational, medical, scientific, or policy-making conference or seminar, (ii) certain limited honoraria and payment of the expenses of a health care professional who serves on the faculty at a bona fide significant educational, medical, scientific, or policy-making conference or seminar, (iii) bona fide clinical trial arrangements, (vi) certain limited bona fide research projects, (v) expenses relating to technical training of individual health care professionals on the use of a medical device pursuant to a written agreement.

Manufactuers need to report “any allowable expenditure or gift … to any health care provider” or “to an academic institution or to a professional, educational, or patient organization representing or serving health care providers or consumers” in the following categories:

  • “The loan of a medical device for a short-term trial period, not to exceed 90 days, to permit evaluation of a medical device by a health care provider or patient.”
  • “The provision of reasonable quantities of medical device demonstration or evaluation units to a health care provider to assess the appropriate use and function of the product and determine whether and when to use or recommend the product in the future.”
  • “The provision, distribution, dissemination, or receipt of peer-reviewed academic, scientific, or clinical articles or journals and other items that serve a genuine educational function provided to a health care provider for the benefit of patients.”
  • “Scholarship or other support for medical students, residents, and fellows to attend a significant educational, scientific, or policy-making conference or seminar of a national, regional, or specialty medical or other professional association if the recipient of the scholarship or other support is selected by the association.”
  • “Labels approved by the federal Food and Drug Administration for prescribed products.”

Manufacturers must report, on form specified by the attorney general, the value, nature, and purpose of each allowable expenditure, and permitted gift along with (i) the name of the recipient, (ii) the recipient’s address, (iii) the recipient’s institutional affiliation, (iv) prescribed product or products being marketed, if any; and (v) the recipient’s state board number.

Failure to manufacturer of prescribed products that fails to disclose as required by the law subjects the manufacturer to a civil penalty of no more than $10,000.00 per violation. Each unlawful failure to disclose, however, constitutes a separate violation.

The legislation also directs the attorney general’s office to conduct a review, in consultation with the commission on health care reform, of the advisability of modifying the law to require the disclosure of information about the provision of pharmaceutical samples to health care providers.   At present, samples are expressly excluded from the reporting regime.

If signed into law, the law will take effect July 1, 2009, but reporting activities under new regime will be implemented in 2010 reporting period.

Clearly the legislature had cost on its mind in enacting the law, as it also has tasked a state workgroup to explore generic alternative formularie recommendationss.   The workgroup is to report to the legislature by January 15, 2010 on the list generated.

Filed under: AKS, Conflicts of Interest, Health Law, , , , ,

TED Talk: Reimagining Global (Health) Data

I just love these TED talks. I previously have postedabout TED. I first discovered it when Pogue (NYT columnist) was talking about the conference and the wonderful web site. This talk is by Hans Rosling who was confronted by a dilemma. There’s tons of great data out there that tells wonderful stories about the world that can inform policy, destroy myths, demonstrate compelling trends, affect both our views of the world and what we have done and can to to improve. But tables and non-interactive graphs are just incredibly boring — and the underlying stories can be completely missed. Take a look at his presentation and then take a visit to his site. Kudos to Health Economist blog to turning me onto this. Really neat stuff. I’m trying to think how I could use something like this in a presentation (even being a lawyer — has to be something creative I can glom onto here).  About Hans Rosling from TED:

Even the most worldly and well-traveled among us will have their perspectives shifted by Hans Rosling. A professor of global health at Sweden’s Karolinska Institute, his current work focuses on dispelling common myths about the so-called developing world, which (he points out) is no longer worlds away from the west. In fact, most of the third world is on the same trajectory toward health and prosperity, and many countries are moving twice as fast as the west did.

What sets Rosling apart isn’t just his apt observations of broad social and economic trends, but the stunning way he presents them. Guaranteed: You’ve never seen data presented like this. By any logic, a presentation that tracks global health and poverty trends should be, in a word: boring. But in Rosling’s hands, data sings. Trends come to life. And the big picture — usually hazy at best — snaps into sharp focus.

Rosling’s presentations are grounded in solid statistics (often drawn from United Nations data), illustrated by the visualization software he developed. The animations transform development statistics into moving bubbles and flowing curves that make global trends clear, intuitive and even playful. During his legendary presentations, Rosling takes this one step farther, narrating the animations with a sportscaster’s flair.

Rosling developed the breakthrough software behind his visualizations through his nonprofit Gapminder, founded with his son and daughter-in-law. The free software — which can be loaded with any data — was purchased by Google in March 2007. (Rosling met the Google founders at TED.)

Rosling began his wide-ranging career as a physician, spending many years in rural Africa tracking a rare paralytic disease (which he named konzo) and discovering its cause: hunger and badly processed cassava. He co-founded Médecins sans Frontièrs (Doctors without Borders) Sweden, wrote a textbook on global health, and as a professor at the Karolinska Institut in Stockholm initiated key international research collaborations. He’s also personally argued with many heads of state, including Fidel Castro.

Filed under: Health Law, Personal Posts, Public Health, , ,

Haunting Images

I found this article interesting as it is local in flavor and surrounding what some might think is a morbid topic.  I disagree, and can see why dissection of a cadaver would be a central experience in the education of medical student. When I was in high school, I interned at the Cuyahoga County Morgue and observed an autopsy.  There I learned that Quincy (yeah, I’m that old and way before CSI) was not really how it worked.  I became an attorney, of course.

diss-colorCWRU’s Allen Memorial is putting on an exhibition of photos from a century or more ago showing medical students with their cadavers.  Many of the exhibits and photos are from the recently published book, Dissection, Photographs of a Rite of Passage in American Medicine 1880-1930 by James Edmonson from Case Western Reserve University and John Harley Warner from Yale University.  As is discussed in the link to the photo below, during this era there was limited access to cadavers for anatomical teaching.  So, learning, for many students, required a bit of self help.  We’ll leave it at that.  The link on the photo at left has some of these photos.

I find the photos fascinating.  Here we are, seeing photos of these student in the prime of their life exhibiting their anatomical subjects, that they treat well, humorously or in poor taste, but that all recently lost of the spark of life.  And these students, too, are now long, long since passed.  From the Plain Dealer article:

dissectionLong before “Tales from the Crypt ” “The Twilight Zone” and horror author Stephen King there were medical students.  Students who at the turn of the 19th-to-the-20th century posed for photos with bodies they had dissected in their studies; who gathered in groups around flesh-peeled cadavers and skulls like hunters displaying trophies…Dissection portraiture had its heyday from 1880 to 1930…The photos were a visual representation of a rite of passage dissection to a new identity a “boundary-crossing experience that left the participant forever changed ” as Warner wrote in the book…Back then there was no legal means of obtaining bodies for dissection. Some were unclaimed bodies but many were provided by grave-robbers known as “professional resurrectionists.” … Warner described most of the photos as almost “reverential” in the treatment of the subject some bearing such phrases written on the dissection tables as “Know Thyself ” “Man s usefulness endeth not with death” and “Her loss is our gain.” But he noted that others the gag photos and macabre images almost seem to revel in the transgression — posing human remains in outlandish poses or providing such accompanying table-epigraphs as “Such the vultures love ” “Rest in pieces” and “The Lord giveth We taketh away.”

via Case Western Reserve University’s Allen Memorial Medical Library displays ‘Haunting Images’ from a century ago – Metro – cleveland.com.

Filed under: Bioethics, Health Law, Personal Posts, , , , ,

Continuing 1Q Drops In GDP and Increasing Effects in Healthcare Sector

I recently posted on a WSJ article and Reuter’s research paper on the effect of the current recession on hospitals and the healthcare system job growth.   The AHA recently surveyed over 1,000 community hospitals (of the nearly 5,000 to which they sent surveys) seeking information on the recession’s effect on the hospital sector.   Similar to the Reuter’s paper from last month, the AHA’s survey shows significant effects on hospital total margins, operating margins, efforts to reduce costs, capital plans.

Healthcare tends to be recession resistant industry, but “The Great Recession” seems to be taking its toll.  And 1Q 2009 reports of economic contraction is worse then expected.   The Department of Commerce in a report issued this morning said that real GDP decreased at a remarkable annual rate of 6.1% Q1 2009.  In Q4 2008, real GDP decreased 6.3% and .5% in 3Q 2008.   Many economists had expected a 4.7% decline in GDP for the Q1 2009.  This is the worst two quarters in more than 60 years.  Since 1947, the economy “had never contracted by more than 4% for two consecutive quarters,” according to MarketWatch.com.  Three consecutive quarter losses has not occured since 1975.

Of note from the AHA survey summary of hospitals:

  • 90 % have taken steps to reduce costs
  • 80 % have reduced administrative expenses
  • 48 % have reduced staff
  • 20 % have reduced services in subsidized service areas
  • 58 % have had at least a moderate increase in uninsured ER visits
  • 70 % have had at lease a moderate increase in uninsured/Medicaid
  • 59 % report at least a moderate decrease in electives
  • 55 % report at least a moderate decrease in admissions
  • 65 % report at least a moderate decrease in total margin
  • 39 % report a significant decrease in total margin
  • 57 % report at least a moderate decrease in operating margin
  • 43 % expect a negative total margin 1Q 2009 (vs. 26% 1Q 2008)
  • 59 % report a at least a moderate decrease days cash on hand
  • 77 % are reducing capital spending
  • 46 % are scaling back established programs for capital spending
  • 54 % have discontinued planned (not started) capital projects
  • 65 % have seen increase in physicians seeking “financial support”
  • Of these 79% for call or other services; 71% seeking employment

via AHA : Press Release : Economic Downturn Taking Toll on Patients and Communities Hospitals Serve: New Survey Finds.

Filed under: Health Law, , , ,

The Future is Here; Just Not Evenly Distributed

Interesting presentation by Futurist Jim Carol.  He asks, what will we learn if we look back to today’s health care system from the vantage point of 2020?  Many of these concepts are not completely novel, so it reminds me of the science fiction writer William Gibson who observed that “the future is here; it’s just not evenly distributed yet.”

From Jim Carol’s presentation “It’s January 15, 2020: What Have We Learned About Healthcare in the Last Decade?”, he discusses a number of trends that he thinks will reshape health care.  A few:

  • Focus on preventive medicine reshapes healthcare delivery and finance, and by 2020 patients are treated for the conditions we know they are likely to develop, rather than principally for those that they already have.
  • Focus on “customer service” as job #2 (#1 always the efficient and effective delivery of care) reshapes healthcare delivery and rebuilds the entire philosophical underpinning of the system, so that “customer focused, friendly, fast, subject to expectation metrics makes it more consistent with other economic industries.”
  • “When Silicon Valley got involved in a big way, everything changed” launching “new products, new business models, scientic discovery tools, bio-informatics platforms that provided the foundation for diagnostic medicine, and many other incredible items.”
  • “Bio-connected devices — home health care medical monitoring, diagnosis and treatment devices — [will] provid[] … a renaissance” in the modality of care.  “A good proportion of both critical and non-critical care patients [will] receive …at home… [causing a] transition[] to a virtual community oriented caregiving strategy which has resulted in cost reductions and a refocus of critical health care spending” away from inpatient services.
  • “[T]he role of medical packaging [will] transition[] from being a passive protector of the product, to becoming an active component of the overall effectiveness of the particular medication” — prescription bottles will have internet enabled RFID tags with bio-sensors, providing specific information to patient’s provider and general information to pharmecutical clinical trials about patient’s current condition and the efficacy and interactions of the drug.
  • By 2020, “the average doctor and nurse [will need to] refresh[] their entire knowledge base every 18 months [due to the velocity of innovation, knowledge growth and change].  The result [will be] that the relationship between medical colleges and students [will] change[], from a period of short term, concentrated knowledge delivery, to one of lifelong, ongoing replenishment and rejuvenation of knowledge.”

via It’s January 15, 2020: Do you know where your healthcare system is? | WorldHealthCareBlog.org.

Filed under: Health Law, Reform, ,

Podcasts I’m Listening To – Week of 4/15 – 4/26

Show Podcast
And Justice For All We The People Stories
Senator George McGovern on Abraham Lincoln We The People Stories
Using Tiny Particles To Answer Giant Questions NPR: Science Friday Podcast
It’s All Politics April 9 2009 NPR: It’s All Politics Podcast
NYT: Science Times for 4/07/2009 Science Times
CIA Interrogation Memos, Possible U.S.-Cuba Talks Top Week’s News NewsHour with Jim Lehrer Podcast | PBS
EPA Finding Opens Door to Regulating Greenhouse Gases NewsHour with Jim Lehrer Podcast | PBS
Newly-released Memos Detail Harsh CIA Interrogation Tactics NewsHour with Jim Lehrer Podcast | PBS
Fighting America’s ‘Financial Oligarchy’ NPR: Fresh Air Podcast
Kristin Chenoweth Is ‘A Little Bit Wicked’ NPR: Fresh Air Podcast
NPR: 04-17-2009 Fresh Air NPR: Fresh Air Podcast
‘Hey I’m Dead!’ The Story Of The Very Lively Ant NPR: Hmmm…. Krulwich on Science Podcast
#354: Mistakes Were Made This American Life
#378: This I Used to Believe This American Life
The American Presidency We The People Stories
From Revolution to Evolution We The People Stories
The Future of the Republican Party We The People Stories
Legacy of 1808: Deconstructing Reconstruction We The People Stories
The NAACP Centennial We The People Stories
Better Brewing Through Synthetic Biology NPR: Science Friday Podcast
Green DIY Projects To Reduce, Reuse, Recycle NPR: Science Friday Podcast
Harnessing Nanoparticles For Targeted Cancer Treatment NPR: Science Friday Podcast
Is Missile Defense Ready For Prime Time? NPR: Science Friday Podcast
Skunked? Tomato Juice Is Not The Answer NPR: Science Friday Podcast
Shields, Brooks Mull Torture Memos, Obama’s Leadership Shields and Brooks | NewsHour with Jim Lehrer Podcast | PBS

Filed under: Personal Posts, ,

The Human Analog to a Pet or a Public Resource?

Uwe Reinhardt has a piece on the Economix blog arguing for universal coverage and public financing of children’s health insurance through age 22.  Dr. Reinhardt is a professor of economics at Princeton University and a leading health policy expert.

What’s most notable about his post is his provocative start.  He asks the question:  do we in the United States view children as the “human analogs of pets … or…, as most European and Asians, as precious national treasures.”  Kind of  a disturbing question, when you think about it.  What’s he getting at?

He believes that answering this question “informs the nation’s health policy.”

If …the human analog of their parents’ pets, then … children’s health care is primarily the parents’ financial responsibility [and]…it is just and proper that, of two households with identical incomes, the one with children will have substantially less discretionary income …than does the childless household.  [I]f …national treasures — and the nation’s economic future — then …health care of children [is] the financial responsibility of society as a whole, just as is the financing of public elementary and secondary education.

Aside from remarking about S-chip and the 9 million children that are estimated to be uninsured, he also observes that Americans “seem to impute different social values to the health care of children, depending on their socioeconomic status, even if they have insurance.”  In other words, there can be a hundred dollar or more swing in basic primary care reimbursement depending whether a child is insured through private payors or public public programs.  And this price signal has real effects – many physicians, including many in Reinhardt’s New Jersey, will simply refuse to see Medicaid patients.

He then goes on to argue that a system similar to our public school system — but with vouchers for parents who would opt out of the public system — should be established for all American children under 22:

The purchasing function under this public program, that is organizing and managing care, could be delegated to private for-profit or nonprofit insurers, as in Medicaid Managed Care. Private insurers would then compete over the quality of their disease-management programs, not through judicious risk selection…[T]he fees paid providers under the public program would be set equal to the average of fees paid by the largest two or three private insurers in the state, lest the professional work of physicians caring for poor children continue to be relatively undervalued.

I think this is interesting reading in light of the McKinsey Study that I posted on recently.  If suboptimal health care is a contributing factor to sub-standard educational attainment of differing racial groups or social/economic classes in the United States, how much does our current health care financing system contribute?  How much, if any, lost GDP opportunity are we leaving on the table due to suboptimal financing of health care for children K-12?   If, as Dr. Reinhardt argues, health care for this cohort should be a public good, what’s the real GDP return on investment to Dr. Reinhardt’s program?  To me, asking and answering these questions are critically important to advance the policy debate.

via Seriously, What Is a Child? – Economix Blog – NYTimes.com.

Filed under: Bioethics, Health Law, Reform, , , ,

Birds or Pigs; The Swines Have It?

We’ve had a lot of stories the past several days about the swine flu outbreak in Mexico and smaller groupings of confirmed cases in New York, California and elsewhere in the United States.   There has been years of discussion on the H5N1, so called avian flu, pandemic risks.  We all remember the impact of SARS.  And we’ve been rocked, recently, by what some have tagged a ‘depression’ but all of noted as the largest economic downturn since The Great Depression.  The losses associated with this ‘Great Recession’ are still playing out.

But I was wondering — what if the Swine Flu became a pandemic at this time?  All indication (including the CDC site) indicate that aside from some serious implications for Mexico City’s public health, the cases in the United States have been mild, with no hospitalizations.  The 1918 flu pandemic that took 20m lives world-wide, however, is the standard modern example of potential personal and economic costs of a flu pandemic.  Not to minimize the terrible pain and suffering that such a pandemic would cause by putting an economic slant on it– but I was wondering what might be the economic impact to our already tottering United States economy if a pandemic struck.

So I took a look at a study the CDC had commissioned in 1999.  It showed the potential U.S. economic impact of a pandemic.   The CDC used this as a way to assist the public policy discussion in light of strategies regarding flu immunization — i.e., which immunization policy could provide the best net value in the case of flu pandemics of differing severity.   It’s beyond this post (or its author) to analyze the article and it’s conclusions.  But I thought the numbers were notable and summarize the potential economic exposure (without vaccination).  And, of course, this looks at U.S. exposure only.  A pandemic would have a far reach.  Look how quickly in this age of easy travel the virus spread from Mexico to the United States and even potentially exposed the President of the United States during his trip.  From the CDC’s study:

Without large-scale immunization, the estimates of the total economic impact in the United States of an influenza pandemic ranged from $71.3 billion (5th percentile = $35.4 billion; 95th percentile = $107.0 billion) (gross attack rate of 15%) to $166.5 billion (5th percentile = $82.6 billion; 95th percentile = $249.6 billion) (gross attack rate of 35%) (Table 6). At any given attack rate, loss of life accounted for approximately 83% of all economic losses. Outpatients, persons ill but not seeking medical care, and inpatients accounted for approximately 8%, 6%, and 3%, respectively, of all economic losses (Table 6) (Appendix II).

* * * *

If it cost $21 to vaccinate a person and the effective coverage were 40%, net savings to society would result from vaccinating all age and risk groups (Figure 2). However, vaccinating certain age and risk groups rather than others would produce higher net returns. For example, vaccinating patients ages 20 to 64 years of age not at high risk would produce higher net returns than vaccinating patients ages 65 years of age and older who are at high risk (Figure 2). At a cost of $62 per vaccinee and gross attack rates of less than 25%, vaccinating populations at high risk would still generate positive returns (Figure 2). However, vaccinating populations not at high risk would result in a net loss (Figure 2).

via The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention.

There’s also an interesting Congressional Budget Office (CBO) assessment (and see generally the goverment web page)  of possible economic effects of an avian flu pandemic.  That study concludes that a pandemic involving a highly virulent flu strain (such as the one that caused the pandemic in 1918) could produce an impact worldwide similar in depth and duration to an average postwar recession in the United States — but citing studies ranging from a .5% to 6% decrease in GDP.  Query, of course, what impact if such a pandemic hit during an ongoing recession.

Filed under: Comparative Effectiveness Rearch, Health Law, Personal Posts, Pharmacy, Risk Management, , , ,

I.M.F. Puts Bank Losses From Crisis at $4.1 Trillion – DealBook Blog – NYTimes.com

A recent IMF report increases the total write-downs that are anticipated wordwide as a result of the current financial crisis.  These numbers are just simply staggering:

[T]he International Monetary Fund estimates that banks and other financial institutions face aggregate losses of $4.1 trillion in the value of their holdings as a result of the crisis…[F]inancial institutions would have to write down an estimated $2.7 trillion in loans and securities originating in the United States from 2007 to 2010…Banks are expected to shoulder about two-thirds of the write-downs…though other institutions, like pension funds and insurance companies, also face heavy losses…Banks have raised about $900 billion in fresh capital since the crisis began…, but that is far outweighed by $2.8 trillion in credit-related losses. The fund estimates that the banks have already taken about one-third, or $1 trillion, of those write-downs….United States…banks reported $510 billion in write-downs by the end of 2008 and face an additional $550 billion in 2009 and 2010. In the euro zone, banks reported just $154 billion in write-downs by the end of last year and still face $750 billion. British banks are in somewhat better shape: having written down $110 billion, they face $200 billion more, the fund said.

via I.M.F. Puts Bank Losses From Crisis at $4.1 Trillion – DealBook Blog – NYTimes.com.

Filed under: Personal Posts, , ,

How Might The Education and Healthcare Sectors Be (Economically) Alike?

Thomas Friedman had an interesting op ed today.  He cited a recent McKinsey Study entitled The Economic Impact of the Achievement Gap in America’s Schools.   I read his op ed, but thought to take a look at the summary of the McKinsey Study.  It points out the potential for huge future improvement opportunity in the educational sector, if only that current opportunity may have been lost.  It also discusses an important similarity between the education sector and the health care sector that is worth remark.

Before briefly discussing the McKinsey study, it uses a report, made a generation ago, “A Nation at Risk”, as a springboard.  I just revisited that report this evening.  I recall reading it in an undergraduate education (elective) class a long time ago.  That 1983 report (by the National Commission on Excellence in Education presented to Secretary of Education) began:

Our Nation is at risk. Our once unchallenged preeminence in commerce, industry, science, and technological innovation is being overtaken by competitors throughout the world… History is not kind to idlers. The time is long past when American’s destiny was assured simply by an abundance of natural resources and inexhaustible human enthusiasm…We compete with them for international standing and markets, not only with products but also with the ideas of our laboratories and neighborhood workshops. America’s position in the world may once have been reasonably secure with only a few exceptionally well-trained men and women. It is no longer.

educationThis McKinsey study asks the question: if we had effectively acted in 1983 and closed the international, racial and class/economic gaps in US k-12 educuation, where would we be today?  They stay away from the ‘moral’ and ‘equity’ component of fulfillment of some of the aspects of that old report’s recommendations and keep it at the level of national economic productivity.  The answer is that if we had done better, we’d be, as a society, a lot richer.

We’re now in the midst of the greatest economic downturn in generations.  Economists thinks that the current ‘Great Recession’ has depressed economic output of the United States by somewhere between $1T to $2T.  If the McKinsey study analysis is to be believed, however, we are experiencing staggering lost opportunities in gross national product performance that surpass even those numbers.  The study puts it this way:

[T]he international achievement gap is imposing on the US economy an invisible yet recurring economic loss [of $1.2T to $2.3T per year] that is greater than the output shortfall in what has been called the worst economic crisis since the Great Depression. In addition, the racial [gap of between $310B to $525B per year], income [gap of $400B to $670B per year], and system achievement gap[] [of $425B to $700B] all impose annual output shortfalls that are greater than what the nation experienced in the recession of 1981–82, the deepest downturn in the postwar period until now. In other words, the educational achievement gaps in the United States have created the equivalent of a permanent, deep recession in terms of the gap between actual and potential output in the economy.

Fundamentally,  our society is experiencing lost opportunity and it affects all of us in very real objective ways.  But lost opportunity is opportunity that can be regained.  So, where is this opportunity?  The healthcare sector and the education sector share an important and remarkable trait according to the McKinsey study authors.  As the McKinsey article points out:

The most striking, poorly understood, and ultimately hopeful fact about the educational achievement gaps in the United States involves the huge differences in performance found between school systems, especially between systems serving similar students. This situation is analogous to that found across American health care, where, as researchers like John Wennberg have shown, wide regional variations in costs and utilization of procedures and services exist that bear no relation to quality or health outcomes. In each case, these differences prove there are substantial opportunities to improve…

While at the racial and economic level there are sizable differences in attainment — controlling for these demographic differences one still finds amazing variations in student achievement.   The study authors point out that research shows that these variations “exist at every level in American education: among states, among districts within states, among schools within districts, and among classrooms within schools.”   “Intuition” and “research” suggest that differences in “public policies, systemwide strategies, school site leadership, teaching practice, and perhaps other systemic investments can fundamentally influence student achievement.”

spending3The authors also point out that there seem to be gross inefficiencies in the educational sector.   While they do not extend, by analogy, to the health care sector, I’ve seen other studies that could.  Despite the United State’s very significant per capita education spending, we might have one of the least cost-effective educational systems in the world. The study authors report that by “one measure we get 60 percent less for our education dollars in terms of average test-score results than do other wealthy nations.”  In other words, as the chart from the report shows, we spend more per student to obtain one point on the Program for International Student Assessment (PISA) Math test (2003 data) than any other nation.  We pay a lot to perform far less well than our international peers.

While the authors do not make very specific recommendations regarding reform, ultimately, their main forward looking conclusion can be summed up by the Lord Kelvin observation:  ‘if you cannot measure it, you cannot improve it.’  The corollary — if you can measure it, and use “relentless efforts to benchmark and implement what works[,]” performance can be significantly improved.

This is an interesting and sober read and I recommend it.

Filed under: Comparative Effectiveness Rearch, Health Law, Personal Posts, , , ,

The Public and the Health Care Delivery System

The Kaiser Family Foundation, NPR and the Harvard School of Public Health recently conducted a poll of public attitudes concerning EHR, coordination of care, patient and doctor interaction around effectiveness and cost, the cost of care, the role of government and insurers in cost and comparative effectiveness, the uninsured and cost.  I found a few of the findings from the survey of note.

  • A larger portion of respondents (34%) thought that EHR’s would actually increase costs of healthcare in America than decrease (22%) it.  Even more (39%) thought it would increase their own family’s healthcare costs!
  • There is significant concern about unauthorized access (76%) to online medical records.
  • A significant minority (40%) of Americans report at least minor problems with coordinating care between their different doctors, while half say this is not a problem at all. A smaller minority (17%) say they experience “major problems” coordinating their health care services.   Interesting, those Americans who reported having personally experienced at least three ‘coordination of care’ issues are much more likely (63%) to see overtreatment in the system as a whole compared to other Americans (48%).
  • About half (49%) think that overutilization is a major problem.  Of course, only a minority (16%) say that they have received unnecessary care and a bit more than half (56%) think that insurance companies should have to cover expensive treatments even if they have not been proven more effective than other, less expensive options.
  • A significant majority of Americans  (72%) believe that there is not always clear scientific evidence about which treatment is likely to work best for any one patient.  But only a small minority (9%) say that they have received an expensive medical test or treatment in which a less expensive alternative would have been just as good.
  • A significant majority of Americans (65%) say their doctor’s charges are reasonable and (63%) believe that their doctor is working to keep the cost of their health care down.
  • There is a significant disconnect between the actual cost of insurance and what uninsured Americans are willing to spend for insurance.  Majorities report being willing to pay $25, $50 or even $100 per month for coverage, but only a minority (29%) would pay $200 per month, and only a very small minority (6%) say they would pay $400.  (Nationwide, annual premiums averaged $2,613 for single coverage and $5,799 for family plans in the 2006-2007 period).

The WSJ Health Blog commented on this survey: while patient seem to recognize that there is waste in the system, it wasn’t their physician.  She’s perfect.

Filed under: Comparative Effectiveness Rearch, Health Law, Reform, , ,

Republicans And Universal Health Care (Only Nixon Could Go to China)

Regina Herzlinger (the McPherson Chair at Harvard Business School and author of Who Killed Health Care? (McGraw Hill, 2007); a health care adviser to John McCain’s presidential campaign) writes an interesting op-ed in the Atlantic.  She argues that the Republicans need to seize the moment, realize that the “time for universal health insurance coverage has come” and that they should go to China, figuratively speaking.  “Republicans should…seize the lesson of Nixon’s trip to China”, where in one swoop Nixon brought the middle Kingdom out of isolation and removed the issue from his political adversaries.  [As Spock says in Star Trek VI, there’s an old Vulcan proverb that ‘only Nixon could go to China’ — perhaps only the Republicans can get sustainable health care reform passed?].

Ms. Herzlinger argues that there is a “a massive constituency behind [a potential Republican] policy” and her fellow republicans can do a “better version of universal coverage.”  She highlights challenges with what appears to be the current Democratic plan to rely “on universal coverage through a government-controlled system like Medicare”: (i) distrust government’s ability to apply fiscal controls needed so that any plan would not bankrupt us as Medicare is appearing to do; (ii) concern that the government will control costs by rationing health care to the sick (citing the UK experience with cancer rate survival due to UK’s pathetic approval of new cancer drugs and therapies); (iii) government as a monopolistic buyer of health care could negatively affect the supply of doctors; and (vi) government-controlled system would likely impair the medically and economically important private investment — particularly in the emerging genomic sector.

The Republicans, she argues, should instead offer a “consumer-controlled universal coverage system, like that in Switzerland in which the people, not the government, control how much they spend on health.”  The Swiss choose from 85 private health insurers.  [I believe that the Swiss government causes a degree of plan standardization so that consumers can compare “apples to apples.”]  In Switzerland, the poor shop for health insurance like everyone else, using funds transferred to them by the government.  Rather than the “degraded” Medicaid program, the Swiss poor get the same insurance options that everyone else get.  The Swiss taxing authority, according to Ms. Herzlinger, enforce the mandatory system and achieve 99% enrollment.

This consumer-driven, universal coverage system provides excellent health care for the sick, tops the world in consumer satisfaction, and costs 40 percent less, as a percentage of GDP, than the system in the US. The Swiss could spend even less by choosing cheaper, high deductible health insurance policies, but they have opted against doing so. Swiss consumers reward insurers that offer the best value for the money. These competitive pressures cause Swiss insurers to spend only about 5 percent on general and administrative expenses, as compared to 12-15 percent in the US. And unlike Medicare, the private Swiss firms must function without incurring massive unfunded liabilities. Competition has also pushed Swiss providers to be more efficient than those in the US. Yet they remain well-compensated.

She cautions that the Swiss system is not perfect, we can learn from it.  It maintains some of the same problems we have with fragmented care and poor integration of payments between vertical provider groups for episodes of care.

She concludes by observing that movement to this model will have real economic impacts:

Republicans could enact Swiss-style universal coverage by enabling employees to cash out of their employer-sponsored health insurance. (Although many view employer-sponsored health insurance as a” free” benefit, it is money that would otherwise be paid as income.) The substantial sums involved would command attention and gratitude: a 2006 cash out would have yielded $12,000 — the average cost of employer-sponsored health insurance — thus raising the income of joint filers who earn less than $73,000 (90 percent of all filers) by at least 16 percent. Employees could remain in with an employer’s plan or use this new income to buy their own health insurance.

via Why Republicans Should Back Universal Health Care – The Atlantic Business Channel.

Filed under: Health Law, Reform, , ,

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