With apologies to my more creative predecessors as Health Wonk Review hosts, there’s no theme today. (After all, how could one top Alistair Cookie?) I will get right to the great posts in this week’s edition.
Costs And Premiums. At Managed Care Matters, Joe Paduda explores an apparent disconnect: flat medical costs coupled with rising private health insurance premiums. Joe thinks that the explosion in high deductible plans is holding down health care costs. Many people with these plans don’t have enough money in their health savings accounts to cover those deductibles, which are often about $5,000. Thus, while they “have insurance,” they don’t have access; they delay and forgo care, risking damage to their health. But then why are premiums up so much? Joe’s answer: “Simply put, because there’s nothing (except the ACA’s medical loss ratio requirements) preventing insurers from increasing premiums as they see fit.”
The GOP Reform Approach. Avik Roy uses a speech by House Budget Committee chair Paul Ryan (R-WI) to argue that the difference between the Republican and Democratic approaches to Medicare is not whether to cut the program – both parties propose doing so, Avik says at The Apothecary – but rather who will be in charge: individual seniors under the Republican approach versus the Independent Payment Advisory Board under the Democratic one. Avik also notes that the portable, refundable tax credits proposed by Republicans represent a “universal coverage” plan, and he wishes that Ryan and other Republicans would reclaim that term rather than avoiding it.
Exporting The U.S. Health System. At Health Care Renewal, Roy Poses discusses a report that some U.S. corporate health care giants, under the aegis of the Healthcare Competitiveness Alliance, want the American government to focus on eliminating barriers to the export of our nation’s “health ecosystem,” including insurance, devices, and record-keeping technologies. It would be an understatement to say that Roy does not think this is a good idea. He details the “sorry records” of UnitedHealth Group and Johnson & Johnson, two leading members of the Alliance, and he suggests that the barriers cited by the group are really just “better regulatory systems in other countries which are more able to defend against the sorts of sleazy behavior that has plagued US health care.”
PSA Screening And Essential Benefits. On his blog Improving Population Health, David Kindig makes the case for an evidence-based approach to cost containment through the lens of two recent developments: the recommendation by the U.S. Preventive Services Task Force for men to forgo routine screening for prostate cancer with the PSA test, and the Institute of Medicine (IOM) panel’s recommendation that costs should explicitly be considered in deciding what benefits must be provided by insurance plans. “While limiting services which have benefit is ethically and analytically challenging, eliminating those such as PSA screening with no benefit and even harm is not,” David says, adding: “That the IOM committee should have to make a case for cost consideration in benefit design indicates how far from rationality we have strayed.”
Costs First, Or Benefits First? At HealthBeat, Maggie Mahar takes a somewhat less sanguine view of what she sees as the IOM essential benefits panel’s emphasis on cost control. She notes that the introduction to the 300-page report (which is all that most people will read) uses a grocery shopping metaphor stating that HHS should first decide how much we are willing to spend on health care, then decide what we can cover. Maggie argues that we should first decide what we want to cover, then add up the cost, and she suggests that eliminating services of little or no benefit is likely to make the end result affordable. She also faults the IOM panel for deciding that “essential benefits” should be modeled on the often skimpy benefits that small employers now offer to their workers, rather than the more comprehensive large-employer coverage that most larger corporations offer.
Dealing With Uncertainty. At The New Health Dialogue, Joe Colucci reflects on the reaction to the recommendation by the Preventive Services Task Force that men no longer undergo PSA testing to detect prostate cancer. Citing this weekend’s NY Times Magazine article on the subject coauthored by his New American Foundation colleague Shannon Brownlee, Joe notes that the evidence is pretty clear that PSA testing doesn’t save lives and subjects men to unnecessary follow-up procedures. So why the continued push for testing? Joe mentions the profits from all those procedures and the testing itself, but he particularly emphasizes how uncomfortable many of us are with uncertainty of not knowing whether we have cancer — even when not knowing is probably the best thing.
Informed Decision Making. Gary Schwitzer also discusses Brownlee’s NY Times article (written with Jeanne Lenzer). At the Health News Review Blog, Gary posts a video of a man (discussed in the Times article) describing regrets about his prostate cancer screening and treatment experience. The video comes courtesy of the Foundation for Informed Medical Decision Making, which also posts videos of physicians describing their own decision on whether or not to have the PSA test.”Gary asks: “How many men have their blood tested for PSA without being told? And how many men never hear such a rational discussion as the one embedded in these videos before having the PSA test?”
Medical Liability Realities And Myths. Right here on Health Affairs Blog, Bill Sage offers readers five thoughts on medical liability reform based on his two decades of research in the area: malpractice liability is a marginal pressure on the health care system, not a major one; most malpractice reform rationales are politically motivated; the chest-thumping about attracting physicians by reducing malpractice litigation is overblown; less of a bad malpractice system is not the same thing as a good malpractice system; and if physicians really want damages caps, they should offer the health care system something meaningful in return. What could constitute “something meaningful in return”? Here’s one possibility that Bill suggests: Physicians “could waive their unreasonable objections to advanced practice nurses, pharmacists, and other trained, mid-level providers delivering low-cost, community-based primary care.”
Covering Health 2.0: Video. David Harlow attended the Health 2.0 conference recently and videotaped 18 attendees answering the same two questions: (1) What is Health 2.0? and (2) What are you doing to promote health data liberation? (Hat tip to Todd Park.) He caught an interesting cross-section of attendees, including artist/patient activist Regina Holliday, Health 2.0 cofounder Matthew Holt, and National Coordinator of Health IT Farzad Mostashari. You can view the video on HealthBlawg.
Covering Health 2.0: Tweets. Neil Versel at Meaningful Health IT News covers the Health 2.0 conference in another form, through his series of Tweets from the event. Neil calls this his version of “Short Attention Span Theater,” and he invites readers to enjoy “the juxtaposition between observation, commentary and snark.”
Maternity Care Coverage. The Health Access WebLog urges California Governor Jerry Brown to sign two bills requiring that coverage for maternity care be included in health benefits. Maternity care will be included in the set of minimum essential benefits that must be covered by all insurance plans by 2014 under the Affordable Care Act, the post notes. However, “it is crucial for California to adopt this standard for maternity coverage in 2012 rather than waiting until 2014—not just to provide the benefit to California women, to our health providers, and to taxpayers as early as possible, but also to provide for an appropriate and smooth transition in 2014.”
Explanations Of Benefits. What does an explanation of benefits actually explain? Not much, David Williams concludes at the Health Business Blog after wading through one of his own. “EOBs may have done their job in the day when their only purpose was to let a member know they owed money, but they’re woefully inadequate in the era of consumer driven health care and transparency,” writes David, who also notes that these forms will be changing based on new consumer needs and new rules issued under the Affordable Care Act. On David’s wish list: an easy way to see the impact on plan members and the insurer of choosing one provider over another.
Patients And Quality Information. At the Healthcare Economist, Jason Shafrin tackles one of those knotty perennial questions – why patients don’t make more use of quality information — through the lens of an article on the muted impact of the Nursing Home Quality Initiative. The article by David Grabowski and Robert Town focuses on the effect of provider competition, or lack of it, on the NHQI’s impact; Jason looks at this factor, as well as several others that could hinder patient use of provider report cards.
Who Should Be Called “Doctor”? At The Hospitalist Leader, Bradley Flansbaum explores his concerns as a physician when nurses with advanced degrees introduce themselves as “doctor.” Brad says he is happy to introduce practitioners such as psychologists and optometrists as “doctor” because the different scope of their duties prevents public confusion. However, when a physician and nurse-doctor both use the same title, casual observers can perceive a false equivalence that obscures the sacrifices and untold hours of reading and hospital time involved in physician training. Brad endorses the unambiguous salutation employed by one nurse: “Hi. I’m Dr. Patti McCarver, and I’m your nurse.”
Why Health Care Disparities Exist. On his blog, John Goodman asks a question addressed in the current issue of Health Affairs: Why are there disparities in health care? John’s answer: because it’s free. He notes that everyone who orders a given burger from McDonald’s gets the same burger at the same price, and this is true in areas of health care where the market operates, such as flu shots in walk-in clinics. Yet the orthodox health policy approach is to suppress the market and ration care by nonprice mechanisms, John says, and he offers a number of reasons why this approach inevitably worsens disparities – for example, wealthier, more educated consumers are better at negotiating nonprice barriers.
Colorado’s Insurance Exchange Debate. Like Americans elsewhere, Coloradans are deeply divided over the Affordable Care Act, and Louise Norris at the Colorado Health Insurance Insider reports on how those divisions are playing out as the state attempts to create a health insurance exchange. Republicans are blocking the exchange board from applying for a $22 million federal grant because doing so would require the exchange to conform to federal requirements. The board, which needs the money to create the technology framework for the online portion of the exchange, hopes to address the GOP legislators’ concerns in time to qualify for a second round of funding in December.
Mobile Phone Apps And Patient Behavior. At the Prepared Patient Forum, Jessie Gruman looks at the opportunities, and as importantly the limitations, involved in using mobile phone apps to change patient behavior. “I am convinced that behavioral scientists and app developers will be successful in getting those mobile phones to do what they want them to: deliver clever tailored behavior change strategies directly to us through our mobile phones. And I am equally confident that many of us will try those apps,” writes Jessie, a cancer patient herself. “But if they don’t do what we want them to —if they become a burden, an intrusion or a bore —we will ignore them, delete them, or, when all else fails, carefully place our beloved phone in the vegetable drawer of the refrigerator and head out the door,” as a friend of Jessie’s with Alzheimer’s does when she tires of being “spied on” by caregivers through a locator app on her phone.
Grantmaking Criteria. Help us spend $100,000,000! John A. Hartford Foundation program director Chris Langston issues that call on the foundation’s blog health AGEnda. More specifically, Langston requests the counsel of readers in beginning the process of allocating his organization’s 2013-2017 grants in ways that have game-changing impacts on the lives of older adults. Since the process is just beginning, Langston isn’t yet asking for specific project ideas; instead, he is seeking thoughts on the nature of health and aging and the broad societal forces that are relevant, since “many disagreements about strategy stem from different understandings of the nature of the problem at hand.”
Ambivalence About Health Care Spending. As the Super Committee debates ways to cut spending, Brad Wright suggests that the biggest barrier to restraining the growth of health care spending is … us. “We” want access to the best care possible, even though we don’t necessarily want to pay for “them” to have it, too. But there is hope, Brad suggests on his blog Wright On Health: “If ‘I’ can be expanded to ‘we’ or ‘us’ and still make sense, then why can’t we expand our scope so that ‘we’ includes all Americans”?
Predictive Modeling. At Workers’ Comp Insider, Tom Lynch looks at how predictive modeling can affect the claims process by identifying injured workers who are most at-risk for delayed recovery or being out of work longer than is medically necessary. “Predictive modeling has long been used in personal lines, especially auto insurance. It’s only in the last 8 or 9 years that we’ve seen it squeezing through the workers’ compensation front door in the areas of underwriting and claims administration,” Tom explains.
Transparency And Generic Drugs. At Drug Channels, Adam Fein reports on CMS implementing an Affordable Care Act provision that provides transparency to generic drug costs for the first time. “With little fanfare, the Centers for Medicare and Medicaid Services snuck out the first draft of monthly Average Manufacturer Price (AMP) data and the new Federal Upper Limits (FULs),” Adam writes. “Whoa. In an easily-downloaded spreadsheet, you can now see average manufacturer selling prices for 719 multi-source generic drugs. More groups are on the way.”
Involving Patients. On her blog Patient POV, Laura Newman complains about the patient being brought into the debate over PSA screening only as a footnote at the end of the analysis. She observes pointedly: “In some parts of the world, medical technology assessment discussions bring patients in from the start before decisions are made on whether or not to cover specific items.”
Religion And Public Policy. InsureBlog’s Bob Vineyard laments that the Affordable Care Act will force Catholic institutions to choose between dropping health coverage for their employees and violating church teaching by purchasing health plans that pay for sterilizations, contraceptives, and abortions. “At this point there does not seem to be a way for Catholics to follow their faith without coming into direct conflict with the mandates of the Obama administration,” Bob writes.
Business And Health Care. Jonena Realth writes at Healthcare Talent Transformation that she has been watching a lively LinkedIn discussion among health care executives, and “the one piece of the puzzle I haven’t heard mentioned is that of patients now demanding that their health care be more cost-effective.” One way to make care more cost-effective would be to limit damages in malpractice suits, Jonena argues.