Archive for December, 2008
by John Goodman
December 29, 2008 at 2:51 pm · Filed under Uncategorized
John Goodman is the president of the National Center for Policy Analysis
Baby boomers. There are about 78 million of them, and they have retirement on their minds. If the past is a guide to the future, more than 80% of them will retire early (before eligibility for Medicare) even if they are not now planning on it. Even if the husband waits until age 65 to retire, chances are his wife will be younger than 65. Two-thirds will not get health insurance from their former employer and even those who have been promised employer coverage (like GM workers - see here) may see those promises broken. So millions of baby boomer early retirees will soon:
a. Discover that 60 year olds cost three to four times as much as 20 year olds to insure,
b. Learn what medical underwriting is about, and
c. Learn what it’s like to pay for insurance with after tax dollars.
Under current law, employers mainly have an all or nothing choice. That is, General Motors can include a retiree on its regular health plan at a cost, say, of $12,000 or it can do nothing. What GM cannot do is offer $6,000 pretax to the retiree to apply to a more economical, individually owned plan.
Here is what is needed:
Employers should be able to help retirees obtain individually owned, portable insurance by (a) negotiating premium discounts and (b) paying a portion of the cost with untaxed dollars and/or (c) putting the funds in a health savings account.
Early retirees should be able to pay their share of premiums with pretax dollars.
Both the employer and the employee should be able to save (pretax) in preparation for post-retirement health care.
This is going to be a huge issue. Congress has not acted on the uninsured before because they rarely hear from voters who have a problem. Baby boomers will be different. They have assets to protect and they are very self interested. Fortunately, there are solutions that do not require huge taxpayer burdens.
by Martin Trussell
December 26, 2008 at 11:03 am · Filed under Health IT
The World Health Congress Blog is pleased to introduce its newest contributor, Martin Trussell. Marty is a 25 year veteran of the health care industry who is currently involved in consumer-driven health care and the convergence of health care and financial services. Marty also blogs about health care innovation at The Health Plan Innovation Blog, a forum for innovative thoughts on how to solve for providing affordable health care choices to Americans.
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Health IT Trends Point Way to Savings
Filed Under (Health IT, Healthcare Reform) by Martin Trussell
The latest occurrences on the health plan innovation front seem to include the use of extensive web portals and online tools. These trends are recapped today in an article posted on AIS’s Health Business Daily website.
In the article, Steve Davis points out that, earlier this month, UnitedHealth Group became the first health plan to fully launch itself into the increasingly crowded field of online health content, personal health records (PHRs) and e-commerce. Steve notes that on that same day, Blue Cross Blue Shield of Massachusetts said a new partnership with Google Health would allow its members to import claims-based health information into a PHR. And, finally, he notes that last month, Aetna Inc. said it would give members access to Microsoft Corp.’s HealthVault PHR.
Davis writes that these announcements show a trend among health plans to capitalize on a population that increasingly relies on the Internet for health information, and an expectation that consumers will want to store their health data electronically.
Quoting Michael Solomon, who is an affiliated consultant at Point-of-Care Partners, a Florida-based firm that specializes in e-prescribing and electronic health records (EHRs): “Employers will increasingly demand that health plans…provide tools to help their employees manage their health” he tells HPW. “As more consumers move into consumer-directed and individual health insurance policies, health plans will be faced with an imperative to foster loyalty with their members and help them stay well.” He points to Aetna, which he says is “aggressively promoting” a health portal and PHR to its members through its ActiveHealth Management subsidiary.
However positive these trends appear to be, there are some potential drawbacks. For example, Davis delves into the question of what happens if pharmaceutical companies buy advertising space on the web portal. Also, with respect to the PHRs, he notes that they currently suffer from a lack of interoperability and portability standards meaning that insurers and other stakeholders will need to address differences in formats, content and other technical issues that are obstacles to interoperability and widespread acceptance.
Health Plan Innovation Take: Yes, there are still a number of issues to be worked out before health care can become paperless, but the rewards can be enormous. Just this week, the Congressional Budget Office said that the only healthcare reform plans that are capable of offering reasonable savings relative to their cost are the health IT plans.
by Jaan Sidorov
December 23, 2008 at 9:27 pm · Filed under Disease Management
If you’re interested in having the good, the bad, the ugly, the skinny, the inside track, the talking points, just the facts and or the lowdown when it comes to all things Federal policy health care, you may want to ‘bookmark’ or ‘favorite’ or download two just-released reports on the topic from the non-partisan Congressional Budget Office (CBO). They are briefly summarized in the CBO Director’s Blog. Simplistically stated, it’s up to CBO to give evolving legislation a green light. If there is no green light, that often times means no go. This is a gateway through which all health care reform must pass.
These reports are must reading for staff, lawmakers, policy makers, regulators, academics, employers, reformers, insurers, patient advocates, consultants and readers of the World Health Care Blog. Resist clicking that print icon: these puppies are hundreds of pages long and that shared printer will be tied up for a long long time. Rather, don your glasses, take an NSAID, get a caffeinated beverage and go full screen…. but think about waiting until after the holiday.
The first is ‘Key Issues in Analyzing Major Health Insurance Proposals.’ Describing its 196 pages as an exhaustive review would be an understatement, but the good news is that it’s all there: policy options for reducing the number of uninsured, altering insurance benefit design, changing the regulation of insurance, manipulating the pricing of health care services, expanding health information technology, influencing patient choices and understanding the impact on the national economy.
And a favorite topic, ‘disease management’ (DM), is in there. The Key Issues report recognizes that a prior CBO review and a more recent RAND review of the evidence of cost savings from DM programs was ‘inconclusive.’ It states that reasons include a) the possibility that the fees are too high, b) private plans are not in the business of sharing their results in the public domain, c) there is an economic downside/dilution of having everyone – including persons who may not benefit – participate in DM, d) it’s difficult to intervene early enough and f) conducting clinical trials in this area is very complicated. On the other hand, the report admits that just about every commercial insurer already has DM in one form or another. As a result, it predicts the U.S. impact of any future requirement ‘mandating’ DM in the commercial/private sector is likely to be blunted.
VERY interestingly, however, the CBO report goes on to indicate that ‘certain types of private-sector programs…would have a greater potential to limit federal spending,’ especially if ‘targeted…. toward the …enrollees most likely to benefit from them or most likely to generate savings….’ and if the DM programs have ‘a strong financial stake in the outcome.’ This appears to suggest that the CBO is supportive of including DM as an ingredient in the reform of government-sponsored health insurance under certain circumstances: a) for some, not all chronic conditions, b) aimed at high risk enrollees and c) with DM organization risk sharing. Wow. Double wow, especially since the DMAA issued a statement applauding CBO’s recognition of DM’s ‘potential to reduce costs.’
The medical home is also examined in Key Issues and doesn’t appear to fare as well. The report recognizes that better access to primary care and greater coordination of health care services ‘could’ translate into savings but ‘the impact of medical homes on health care spending remains unclear’ because health care utilization could paradoxically increase. Interestingly, it points out the potential for savings would be greatest if “the coordinating physician had a financial incentive to limit the use of specialty care.’ This means gatekeeping, which is precisely the term used in the CBO report. Ugh. This isn’t what the primary care physician advocates of the Patient Centered Medical Home (PCMH) had in mind.
Head on over to this second report on ‘Budget Options’ and you’ll find a treasure trove of 115 one to two page long summary statements that examine each and every one of the many reforms (except, curiously, disease management) currently under consideration. Option 39 deals with the Medical Home and it echoes the posture in the Key Issues discussion above: ‘CBO cannot estimate whether the net result… would be to increase or decrease spending for the Medicare program.’ T
Is the notoriously dour CBO being cautiously optimistic about the potential role of disease management? What do readers think?
by Jaan Sidorov
December 13, 2008 at 11:33 pm · Filed under Uncategorized
We can telephonically engage/coach/monitor and help persons with diabetes, asthma, heart failure, COPD, coronary artery disease – but how about serious persistent mental illness? Check out this interesting paper published in the latest issue of the American Journal of Managed Care by Paul F. Cook, Suzie Emiliozzi, Corey Waters and Dana El Hajj of the University of Colorado, ScriptAssist and Centene Corporation (the latter two entities paid for the study).
This was a study involving outpatient Medicaid beneficiaries who were taking anti-psychotic medications for more than 30 days. 210 candidates were identified for nurse-based telephony, but only 59 (28%) could be reached on the phone. Of these, 8 declined to participate, leaving 51 intervention patients. The remaining 151 formed a comparison group. The results that caught my eye were that intervention patients visited ERs an average of about 1 time per year, versus 5 in the comparison group. While the comparison group initially had higher pharmacy compliance rates in the first month, by 6 months is was clear that the intervention group was doing much better at taking their anti-psychotic medications at 48% vs. 26%.
This was far from a perfect study. The intervention and control groups are probably not comparable, since patients who can be reached by telephone and agree to participate are probably more compliant in general and are more likely to avoid ERs and take their medicines as prescribed. That’s called selection bias. There was also insufficient detail about the protocols used by the nurses to help the patients.
Think of this as a pilot study. That being said:
Among a population of severely mentally ill outpatients who are notorious for not taking their antipsychotic medications, we’ve learned that it’s possible to reach a quarter of them by telephone and engage them in regular follow-up. This may reduce ER use and it may increase medication compliance. This is worth more study.
There were other lessons learned from this paper. The authors pointed out that there was a delay between the time patients got their qualifying medications and the telephony was initiated. Another was the use of a masked “unknown” caller ID when patients were called (to protect confidentiality), which in turn prompted patients to not pick-up.
Despite all the limitations, I like this study because it’s disease management outside the usual big 5 of asthma, diabetes, heart failure, COPD and coronary artery disease. It uses a well known approach to a population that is very difficult to manage with high levels of avoidable utilization and complications. It was performed in a community setting with high generalizability and had the wherewithal to not only implement a program but simultaneously study the impact at the same time.
It is common in research settings to conclude manuscripts like this with the adage that more research is necessary. The authors of this little gem did that also. However, I’d go one step further and suggest (unless there are better ideas out there) that telephonic follow-up/coaching of persons with mental illness who are on antipsychotics be expanded and that more research be performed to better assess what works and what doesn’t.
by World Health Care Blog
December 11, 2008 at 7:12 pm · Filed under Uncategorized
The below post, wrapping up Day 3 of the 4th Annual World Healthcare Innovation and Technology Congress, is from Tim Edwards, manager of physician relations at University of Texas MD Anderson Cancer Center. His blog is “Misunderestimation”
World Healthcare Innovation and Technology Congress Day 3 Wrap-up and Summary
The final day of the World Healthcare Innovation and Technology Congress began with a bag, Scott McNealy from Sun discussing how Open Source works for healthcare. McNealy’s presentation was incredibly entertaining; equal parts insightful information and stand-up comedy. Here is a sampling of quotes from McNealy:
We must go digital. Just look doctors handwriting and you’ll see, we must go digital.
Open Source is a very old concept that we’ve been doing since 1982. If I can go a little Al Gore here, we invented Open Source.
Public key encryption schemes are the best option. If you have a secret in your code, it will be discovered and breached. Humans cannot keep a secret. What if the Trojan horse was made of glass? Would they have let it in?
When I hear “enterprise license agreement,” I think, “The first hit of heroin is free.”
Technology has the shelf life of a banana; it will be outdated before you can roll it out.
McNealy’s message centered around the very real impact Open Source is having on the market and how that success can be brought to healthcare. Sun has spent $26 Billion on research and development and is currently involved in the creation of the Nationwide Health Information Network (NHIN).
Open Source has tremendous advantages including avoiding “format rot” in archiving information. What happens 20 years from now when someone needs to open a document created in a proprietary tool like MS Word? Or better yet, how does one render a document created in the Wang system? With Open Source you can bundle the files with the rendering agent.
In a nutshell, McNealy says there are 7 reasons to be open
Lower barriers to entry
Increased security
Faster procurement
Lower cost
Better quality code
Open standards last longer
Lower barriers to exit
As a recovering developer, his comments on better code peaked my curiosity. Basically, developers are very protective of their reputations and releasing code into an open environment for the scrutiny of other codes ensures the code is top-notch. Open Source code tends to be written cleaner and documented thoroughly; coders are opening their robes and exposing themselves to the world. They want to look good.
My favorite comments dealt with the privacy question and how it works the same in the Open Source world. First, “Somebody a long time ago someone said you don’t have privacy, get over it. Oh wait, that was me.” And the second quote, dealt with what is perceived now as a secure delivery system, the US Post Office. “You take an 8 x 11 piece of paper, stuff it in a folded paper envelope, seal it with spit, write unblinded information in the outside in the to and from areas, give it to the Federal Government for a couple of days, stick it into a tin box, all with the hopes that it will get there.” Yet somehow we worry about the level of encryption used on networks or go so far as to print everything and take them out of the secure networks to set them on a desk.
In closing, McNealy had one more comment on healthcare that resonated around the room, “There is only one industry more screwed-up than computers and that’s healthcare. You kill everyone eventually, I know you are working on it.”
I found more in that 30 minutes of Scott McNealy then I’ve found in entire conferences. I’m very appreciative of him and his taking the time to speak with us.
Next up, was a presentation on Direct Practice Medicine by Scott Shreeve and Jordan Schlain, two physicians who are delivering healthcare differently. Their belief is it’s not always about the throughput, it’s not always about speed, it’s about relationships. The business model involves seeing considerably less patients to avoid the “hamster wheel” syndrome of running faster and faster but not getting anywhere. Their patients subscribe to their clinic and have 24/7 access to physicians who actually know them and spend time getting to really know them. To pay for the services, subscribers increase decidable in their health insurance and use the money saved to pay the monthly access fee.
What I found intriguing was the level of detail in the understanding of the patient and access to care provided with their model. I’m not a physician, but I suspect most physicians enter practice to get to know and improve the lives of their patients. Somewhere along the line we have deviated into short episodes of disparate care that may be causing more harm then good. Having said that, I wonder what happens to patients who need care beyond what is being delivered in this manner, but I do like the concept. I’m going to watch the continued expansion of this model in the future and you can go to currenthealth.md to learn more.
Unfortunately, after this session, I had to be off to the airport and a return to the real world. However, on the way back, I take a couple of learning with me from the congress
Healthcare is in the midst of a fundamental transformation that is being driven by customers, globalization, economic factors, and an unprecedented influx of technology
Social networking on online communication have a central place in healthcare, both in the delivery of care and the support of the care process not to mention uniting the growing army of reformers who are finding support and ideas in the community.
We still have a long way to go.
I want to thank the organizers of the congress for their hard work in putting together an event that was both informative and entertaining. One suggestion, in the future, you audience members are very tech savvy. Give them tables and outlets so they can document and report on the event, look-up resources being discussed, and possibly participate in events online. Beyond that suggestion, I look forward to next year’s conference.
by John Goodman
December 11, 2008 at 6:03 pm · Filed under Uncategorized
Dr. John Goodman is the president of the National Center for Policy Analysis
At the National Journal Health Blog, Marilyn Serafini asked, “How much does health reform really cost, what elements are worth it, and what are the best and worst options for paying for it?” She invites bloggers to compare the current situation with the passage of Medicare and Medicaid in 1965. [link] Here is part of my response:
Here are five lessons from the Medicare and Medicaid experience:
The cost of Medicare and Medicaid was way beyond what anyone predicted. The reason: failure to realize that when any good or service becomes free, people will consume more of it.
Once started, these programs are extremely hard to curtail. If we ended Medicare today - collecting no more taxes and allowing no more accrual of benefits - we would still owe $33 trillion in benefits already earned! (Results of new NCPA study.)
Looking indefinitely into the future, the Trustees have calculated there is an unfunded liability (promises made over and above expected premiums and dedicated taxes) of $85 trillion - almost six times the size of the entire economy.
According to Amy Finkelstein, although Medicare was financially important to the elderly, it created no discernable health benefits in terms of reduced mortality. [link]
Despite no measurable health benefits, the explosion of spending on these two programs forced up prices for everyone else. In fact, HHS’ own internal estimates suggest that every $1 of additional spending buys 57¢ of higher prices.
“Memories Are Made of This”
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by World Health Care Blog
December 10, 2008 at 1:02 pm · Filed under Uncategorized
Tim Edwards, manager of physician relations at University of Texas MD Anderson Cancer Center, has posted a couple of nice entrires on his blog: “Misunderestimation: Life in the 21st Century” on WHIT. Read here for the Day 1 summary and here for Day 2.
by World Health Care Blog
December 10, 2008 at 11:46 am · Filed under Uncategorized
We had a quite a few WHIT attendees posting their thoughts on Twitter these past three days. Click here to view the feed and type in #WHITC08.
by World Health Care Blog
December 9, 2008 at 9:16 am · Filed under Uncategorized
The first day of the 4th Annual World Healthcare Innovation and Technology Congress is in the books. Yesterday’s packed presentations included a facsinating address by Newt Gingrich, founder of the Center for Health Transformation and former Speaker of the U.S. House of Representatives. Mr. Gingrich engaged the audience with his vision for a transformed health system that dramatically reduces fraud while engaging patients and providers. As a staunch conservative, the former House Speaker favors plans that minizmine government involvement and allow the best solutions to come from the best innovators in the market.
by World Health Care Blog
December 7, 2008 at 2:27 pm · Filed under Uncategorized
The 4th Annual World Healthcare Innovation and Technology Congress (WHIT 4.0) begins Monday, December 8 in Washington D.C. We will have an impressive line up of presenters this year. Scott McNealy, chairman of Sun Microsystems, Colin Angle, CEO of iRobot, Dr. Jeong Kim, president of Bell Labs and Newt Gingrich, founder of the Center for Health Transfromation are just a few. Please check back for posts from our speakers and attendees. The conference runs through Wednesday.
#WHITC08
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