Electronic Health Care
No sooner had the provisions concerning health care in the House's economic stimulus bill seen the light of day than the defenders of the status quo came out, guns blazing.
One target is the proposed development of a nationwide electronic health information infrastructure. The other is an initiative for "comparative effectiveness analysis," which refers to estimates of the cost of different therapies used to reach a particular outcome (e.g., there are multiple ways to treat high blood pressure, and they all cost different amounts). Both have strong bipartisan support.
The status-quo posse was led by the American Enterprise Institute resident fellow Scott Gottlieb, M.D. He wrote that government involvement in comparative effectiveness analysis is a mischievous Machiavellian plot (a) to deny expensive health care to critically ill patients, especially to cancer patients and the elderly, and (b) to stunt the progress of medical technology in general, all for the sake of saving taxpayers money.
Two weeks later Betsy McCaughey, currently of the conservative Hudson Institute and formerly New York's lieutenant governor, wrote a commentary with the ominous title, "Ruin Your Health With the Obama Stimulus Plan."
Ms. McCaughey warned that a "National Coordinator of Health Information Technology will monitor treatments to make sure that your doctor is doing what the federal government deems appropriate and cost effective," and, further on, that "penalties will deter your doctor from going beyond the electronically delivered protocols when your condition is atypical or you need an experimental treatment."
"In my view, the passages in the plan cited by Ms. McCaughey simply do not support the dire interpretation she puts on them. Nor does comparative effectiveness analysis envision the hard-hearted scenarios conjured by Dr. Gottlieb."
Unfortunately, a defense of the status quo is par for the course in American health policy. If the defense carries the day in the coming debate on health care reform, then the American people have only themselves to blame for the predictable consequences, which are:
First, health-spending per capita in the United States will continue to rise 2 to 2.5 percentage points faster than the rest of per-capita gross domestic product, as it has done for the last four decades. Health care then will absorb about 40 percent of G.D.P. by 2040.
Second, more and more middle- and lower-income American families will find themselves priced out of needed health care, as the cost outpaces the growth in the wage base that supports the families. They will experience harsh rationing of health care, not by government, but by price and their ability to pay.
And, third, the waste most experts impute to our health system would continue unabated, as it thrives on the opaqueness of a heavily paper-based, fragmented health system that shuns comparative effectiveness analysis.
Part of the problem is that the defenders of the status quo always skillfully mingle several distinct issues that ought to be treated separately. These issues, much discussed in the well-respected literature, are:
- Appropriateness: A growing body of scholarly literature suggests that a surprising fraction of the health care given to patients in the United States — and in other countries as well — does not appear to be the clinically most appropriate response to the patient's medical condition.
- Cost-Effectiveness: Even if clinically effective and appropriate, a good part of the health care delivered in this country does not appear to be the lowest-cost therapeutic approach to reach a given therapeutic target (e.g., managing diabetes or controlling blood pressure).
- The Price of Changes in Health Status: As the cost of health care keeps rising, severely straining the budgets of households, businesses and governments, sooner or later we must confront the question of whether there should be an upper limit to the price that should be paid for a given improvement in health status, at least insofar as it is paid for out of collective health-insurance pools in private, commercial insurance or public health insurance programs.
It is hard to see why there should be much controversy about the first two issues, other than among those who profit from inefficiency. Here I would cite what I have called Alfred E. Neuman's Cosmic Law of Health Care, namely: "Every dollar of health spending is someone else's health-care income, including fraud, waste and abuse."
The third issue — the price to be paid for improvements in health status — is very controversial. It touches on deeply philosophical and ethical issues on which honorable people may disagree honorably.
It is true that in the more resource-constrained health systems of other countries the third issue is being gingerly explored. It is also true that millions of American households without health insurance or with shallow insurance necessarily must confront it squarely — for example, when they are asked to pay a coinsurance rate of 30 percent or more for a specialty drug that can cost $100,000 or more for a treatment.
But as far as I know, no one in the Obama administration has put the third issue on the table. These folks will have their hands full merely focusing on first two issues, leaving the third to administrations further in the future.
Breast Cancer and Health Care
Jennifer Lyon had a harder time trying to find affordable insurance for her breast cancer treatments than dealing with her health issues.
"The stress and the worry of how you're going pay for the treatments shouldn't outweigh the illness itself," she said.
After she lost her job and before she lost her health insurance, Lyon had to scramble to schedule her breast cancer surgeries, including a biopsy and lumpectomy.
After that, she spent hours on the phone to try and find other ways to afford the radiation and treatment she would need.
All the while, she was busy applying for a new job and trying to live off unemployment.
She was told she couldn't receive community care from St. Vincent Hospital because she was not poor enough, although her only income was unemployment. Her unemployment totaled $1,200 a month, yet her bills were more than $1,300 a month.
"I mean, I can't even pay my bills," she said, "so I felt that I was indigent."
She contacted a number of cancer foundations and programs for health care and again looked at her options through COBRA.
She was scheduled to begin treatment on Jan. 26, but was told by the hospital that if she didn't have proof of insurance or $5,000 in cash by Jan. 28, she could not be treated.
"That sent me into a tailspin," she said.
Lyon applied for Medicaid but was told it would take a few days to be approved and applying was not enough.
"I was basically told they wouldn't treat me," she said.
Lyon was forced to cancel three of her cancer treatments and wait until she was able to find help.
"I will not be able to make those up and I'm not sure if that will have an impact on the long run of my treatments," she said.
Once her Medicaid application went through, she resumed radiation.
However, years of back pain now have Lyon starting at square one with insurance. Many doctors won't take Medicaid, she said, so she's again searching through her options.
Lyon's health problems and difficulties paying for treatment are not unique.
The President & Health Insurance
President Barack Obama addressed this struggle at Tuesday's joint session of Congress, urging lawmakers to pass health-care reform this year.
"In the last eight years, premiums have grown four times faster than wages," Obama said. "And in each of these years, 1 million more Americans have lost their health insurance. It is one of the major reasons why small businesses close their doors and corporations ship jobs overseas."
According to a new report by the Illinois Main Street Alliance, 12 percent of nearly 500 small businesses polled in a dozen states have dropped coverage for their workers within the past two years. In addition, 35 percent reported switching within the past two years to insurance that covers fewer services.
Average rate increases for 2009 for most large employers are projected to be from 7 percent to just below 10 percent, according to benefits consulting firm Mercer. An individual renewing or purchasing products in the open market can expect premiums to increase by at least 10 percent, Mercer said.
Borris and other small-business owners and individuals are hoping they can become a part of a larger pool to help blunt their premium increases.
Policymakers are looking into both public and private options to fund health care for small businesses, said Kathleen Stoll, deputy executive director for Families USA, a consumer group that has led efforts to build consensus around the health reform campaign.
"There's a lot of talk about how we create a fair marketplace," Stoll said. "If we provide a subsidy for individuals or small business, it can help people maintain coverage. [It] pools risk and does not penalize folks for being older and sicker."
Obama has not officially put a plan on the table, but he and key members of Congress have favored subsidies to small businesses and individuals, the ones often hit hardest by insurance increases and, therefore, more likely to drop coverage.
Another proposal being floated is a publicly funded option similar to Medicare, the health insurance program for the elderly.
The health insurance industry has been open to Obama's ideas but is leaning toward a so-called guarantee-issue model, which mandates individuals buy some form of coverage.
The industry maintains a mandate would limit costs for consumers and small firms. Such a model also would provide insurers with a larger risk pool to pay claims, which helps them turn a profit.
"Guarantee-issue laws without a requirement that individuals purchase coverage can cause significant unintended consequences in the individual insurance market," said Robert Zirkelbach, a spokesman for the lobbying group America's Health Insurance Plans, which represents insurers such as Aetna Inc., UnitedHealth Group Inc., Humana Inc. and some Blue Cross plans.
Without such a requirement, Zirkelbach said, the proposals "may provide an incentive for people to defer seeking coverage until they have health problems, which can cause premiums to increase for all policyholders."
Private Health Insurance
Dave Johnson was part of a group who had lunch with former Presidential candidate Michael Dukakis a couple of days ago. At one point he offered what I think is a great idea. He said that the country should let people buy into Medicare at cost today, while health care reform is worked out.
He said, "I've been thinking about the benefits of this idea. Medicare doesn't have to pay any CEOs hundreds of millions a year, or give million-dollar bonuses to management. Its overhead is microscopic compared to the overhead of private insurance companies, so their costs are much lower."
Companies that provide employees with insurance could immediately lower their costs dramatically. Just transfer all the employees over the the Medicare buy-in plan instead of the expensive private insurance company plans they now buy.
- Individuals who now buy their own insurance could immediately reduce their own costs.
- Some people who cannot afford health insurance today could afford to buy into Medicare.
- Every doctor's office already handles Medicare claims, so this would greatly reduce the current overhead costs of doctor's offices.
- This would bolster the Medicare program.
- People would get better health care because Medicare doesn't deny treatments to increase their own profits.
- People would actually be insured because Medicare doesn't look for reasons to cut off coverage when people get sick, like private insurance companies do.
In other related news
PRIVATE health insurance has shown a slight lift in memberships, defying speculation that easing government penalties on non-joiners would result in a health fund downturn.
In the last quarter of 2008, private health insurance membership grew by 54,000 people, or 0.1 percentage point.
A total of 44.8 per cent of all Australians were covered by private hospital insurance, the highest proportion of people covered for hospital treatment since December 2001.
This is the first release of membership figures for the period since the confirmation of Government changes which will lift from $50,000 to $70,000 the annual income a single person can earn before having to choose between taking out health insurance or paying a 1 per cent surcharge on the Medicare levy. For couples, the threshold rose from $100,000 to $140,000.
The Government said the changes would deliver tax cuts to 250,000 Australians. The changes do not take full effect until next financial year, although it had been expected that at least some people who could opt out of insurance beforehand would do so.
The figures released yesterday by the Private Health Insurance Administration Council show that membership has grown, even among the 25-29 age group who would normally be the most likely to drop insurance.
When thechanges were introduced last year, the Opposition and health insurers attacked it as a measure that would cut the number of insured people.
The Opposition's then health spokesman, Joe Hockey, said last May that membership, at that stage at 44.6 per cent of the population, would be a high point. He said because of the Government changes, there was "only one way the private health sector can go under the Rudd Government and that's down".
The Health Minister, Nicola Roxon said the modest growth was encouraging. "Given the economic circumstances, the Government will continue to closely monitor membership numbers over the coming months," she said.
The chief executive officer of the Australian Health Insurance Association, Dr Michael Armitage, said the result vindicated research that once members had used their health insurance and realised its value, "it remains one of their last discretionary spends, even in difficult economic times". It was vital that the Government stay committed to a strong private health sector.
The Opposition's health spokesman, Peter Dutton, stuck with the view that the increase in the Medicare surcharge threshold would reduce the number of Australians with private health insurance.
Hospital Care Suffering in Economy
The economic decline is continuing to ravage the nation's hospitals, with half of them operating in the red and many planning service and staffing cuts, two new reports show.
Hospitals are ailing because of a number of problems hitting in close succession. First, hospitals' investment incomes plummeted -- like everybody's -- eliminating a cushion for operating budgets and curtailing capital spending.
Then, the mix of patients began to shift: Paying admissions declined as people put off elective procedures and insurers tightened their grip on the length of hospital stays they covered. And the number of patients without insurance or the means to pay their part of the bill began to rise.
These problems have been surfacing for several months. But new data show their breadth and depth. Indeed, an unprecedented 50% of the nation's hospitals appear to be losing money, according to an analysis of government and proprietary data that Thomson Reuters is set to release today.
When the slide began, returns on investment were the primary culprit, according to Thomson's analysis of data on a cross-section of hospitals. Total margins for every type of hospital -- public, private, for-profit and nonprofit -- declined in 2008, the analysis found.
Hospital operating margins -- the extent to which operating income exceeds expenses -- remained fairly consistent through the third quarter of 2008. But nonoperating margins, composed primarily of investment income, started to fall in late 2007, and the decline accelerated in mid-2008.
"This dragged down the median total margin to near zero and left approximately 50% of hospitals in the red," the analysis concluded. "When we compare these total margin statistics with historic data, we find that medians this low have not been observed before."
The 25% of hospitals in the worst shape posted margins below -7%, or 7% worse than the break-even point, while the top performers' margins exceeded 4.5%.
Even operators of the most robust hospitals are bracing for another difficult year as the effects of layoffs and employer cuts in health insurance benefits take hold.
"We will see our charity care numbers go up as a result of the current economic situation, and we'll also see our bad debt go up and people who are unable to pay their bills," said Deborah A. Proctor, the chief executive of St. Joseph Health System, based in Orange.
The nonprofit system -- which runs 14 hospitals in California, New Mexico and Texas -- ended its last fiscal year with a healthy 4.8% margin. That will be a tough mark to achieve this year because of the anticipated increase in uninsured and underinsured patients, Proctor said.
"It will hit all hospitals," she said. "Those who are already in negative revenues will probably see that get worse as things go along."
Forty-four percent of hospitals have seen declines in surgeries, with hip procedures showing the steepest drop-off at 45%, according to another new survey. As a result, 47% of the hospitals surveyed expect to make staff cuts, and 69% plan to cancel or delay equipment purchases, according to the survey by Novation, a company that manages supplier contracts for hospitals.
Novation has responded by demanding that vendors maintain or roll back prices on the goods they sell to hospitals.
"We know that the weakened economy has hit hospitals particularly hard, and they are being forced to make some tough decisions," said Novation President Jody Hatcher. "In November, we took a bold 'no increase' pricing stance."
Proctor said the St. Joseph hospitals may have to delay building projects and equipment purchases. But she said she did not anticipate layoffs or service cuts.
"We have to operate more effectively and more efficiently" to meet the needs of the growing ranks of uninsured and underinsured, she said. "However, it will not keep us from providing in those situations. That's our mission. It's always been our mission to serve the least among us."
The foundation arm of St. Joseph was set to make a down payment on a healthier future this year. It had long planned to roll out a $3-million, three-year attack on childhood obesity in Orange County through medical screenings, as well as nutrition and exercise programs in schools.
Proctor said the organization proceeded with the effort in spite of the economic downturn in the belief that it would eventually pay dividends for the community.
"We did not in any way back away from this program," she said. "This was a key commitment for us."