HealthBlawg

Wal-Mart and SEIU: Who drank the Kool-Aid?

Wal-Mart and SEIU, together with other large employer and union reps, formed the Better Health Care Together coalition and held a press conference yesterday.  Check out coverage in the N.Y. Times and the excellent roundup (including reactions from all angles) from the Kaiser Network's Daily Health Policy Report.  The latter summarized news reports thus:

The purpose of the coalition -- called Better Health Care Together -- is to "end the nation's reliance on employer-backed health insurance and develop a system for providing universal low-cost coverage within five years."  While the coalition offered no specific plan, it outlined four broad themes to fulfill this purpose: health coverage for every U.S. resident by 2012; shared financial responsibility by businesses, government and individuals; a sense of personal responsibility for maintaining health; and a more efficient health care system.

Summit to start working out the details will be held in May.

So, who drank the Kool-Aid? 

Unions see the writing on the wall -- generous employment-based benefit packages are contributing to layoffs and buyouts, so unions need to serve their membership (and themselves, by ensuring that they can stave off loss of membership through buyouts, early retirements, etc.) by rejiggering this piece of the social contract.

Big employers are eager to embrace the President's rhetoric about decoupling health care coverage from employment because it's so damn expensive.

And now folks on both sides of the table come together with this pabulum.

No one can argue against the prompt roll-out of low-cost universal coverage that increases personal responsibility and consumer-directedness of care, and also increases the efficiency of the U.S. health care system.  But what what does it really mean? 

So far, it just sounds like cost-shifting to individuals with a vanishing tax benefit (medical inflation outpaces general inflation, so the value of the President's proposed tax benefit will disappear over time).  Consumer-directed health care -- in the form of HSAs and HDHPs -- still hasn't worked out all the kinks. 

Nobody really knows if this will work.  Maybe it will.  But for now, this exercise is generating more heat than light.

Update 2/9/07: For a more eloquent dissection of the current band-aid approach to fixing the health care coverage system in this country, together with a broad-brush proposal for sweeping reform (slightly more specific than that of the BHCT coalition), see the Victor Fuchs and Ezekiel Emanuel piece in Wednesday's Washington Post.  (See also further discussion and link to a related Fuchs and Emanuel paper at the Health Affairs Blog.)  I agree that wholesale reform would probably be preferable to the incrementalism being bandied about in the political theatre, but I fear it is about as likely to be enacted as "HillaryCare."

-- David Harlow   

Health Wonk Review #25

Welcome to the Silver Edition of Health Wonk Review, celebrating HWR's 25th bi-weekly installment.  No need to wait for the 50th installment to celebrate; in the words of the immortal bard, "All that glitters is not gold." 

To quote another poet:

All that is gold does not glitter,
Not all those who wander are lost;
The old that is strong does not wither,
Deep roots are not reached by the frost.
From the ashes a fire shall be woken,
A light from the shadows shall spring;
Renewed shall be blade that was broken,
The crownless again shall be king.

Those of you who are J.R.R. Tolkien fans will recognize these lines and appreciate them in their original context; others may wish to read into these lines some echoes of their own thoughts on the current national political scene.  I'll leave my own thoughts unspoken; feel free to divine what they may be -- but please, no wagering.

On to the task at hand.

This past fortnight could have been dominated by posts concerning the President's health plan unveiled in the State of the Union address.  Instead, I would say that the plan has served as a trigger for broader debate.

There were, of course, posts on the plan.  I think Matthew Holt at The Health Care Blog wins the prize for most comments on a post regarding the Bush plan.  Michael Cannon at Cato @ Liberty stakes out a position that the plan is not a tax hike for some high wage earners.  At Managed Care Matters, Joe Paduda says that the plan will not help the often disenfranchised folks with pre-existing conditions.

Jane Hiebert-White at the Health Affairs Blog notes that health care reform has not lost its luster, and that the interest in health care reform has emboldened the early participants in Decision 2008 to touch this "third rail" and offers links to further discussions of some candidates' views (Clinton and Obama). A Healthy Blog highlights Edwards' plan and sees a Massachusetts influence.

While not one of our usual suspects, Mark Thoma, at Economist's View, brings together a couple of articles about the decoupling of health insurance from employment, including coverage of the winners of this week's strange bedfellows award, Wal-Mart and SEIU. There's some lively discussion in the comments.

Interest in how other countries manage their health care and health insurance systems seems to wax and wane over time; these days, interest seems to be on the rise.  Living through the Massachusetts experience in wrestling with the question of what is an affordable health insurance plan (under the Massachusetts universal health care law) made me think that the intended beneficiaries might have to hock the family silver, if they had any, in order to afford the plans proposed by the HMO's.  A Healthy Blog's post on the subject garnered a lot of comments about European models, their (lower) costs, and whether they were worth discussing.  Here at HealthBlawg, I posted a link to the recent Commonwealth Fund report comparing the rate of growth in costs in the U.S. vs. certain European countries over the past 25 years (and offering prescriptions for slowing the rate of growth here).  InsureBlog's Henry Stern reacts to talk of nationalized health care systems by arguing that the grass isn't always greener.

At The Antidote: Counterspin for Health Care and Health News, Emily DeVoto delves into the American College of Physicians' proposed health plan which, she observes, goes beyond coverage and into prevention and holistic care, in an interview with the College's government affairs VP.

The policy debate extends beyond the issue of coverage.  However, without coverage -- and sometimes without the "right" coverage -- there is no access to timely and adequate health care services.  Jason Shafrin, at Healthcare Economist, has a post up about two studies highlighting the gap between access to emergency services (which is near-universal, thanks to EMTALA) and access to follow-up care (good to dismal, depending on source of payment).

Many states are hard at work on various forms of universal health care plans.  Meanwhile, the Lone Star State is forging ahead with a single-disease prevention effort.  Beth Newell offers her Health Care Musings on HPV, Rationing and Health Ethics.

While I've seen a ton of commentary on the Texas initiative, Roy Poses at Health Care Renewal chews on the dearth of ink (and bytes) on the anechoic story of HRDI.  (Great adjective, Roy.)  In brief, HRDI was a for-profit corporation created, owned and operated by the CEOs of 30-odd prominent U.S. health care systems and hospitals.  The main purpose of this organization seemed to be to sell memberships to select corporations which sell products and services to hospitals, in exchange for face-time with the hospital and health system CEOs.  It was shut down by the Connecticut AG. 

You're probably wondering: What about EHRs?  Well, Micky Tripathi at the MA eHealth Collaborative Blog recently wrote about a malpractice insurance credit now available to Massachusetts docs with EHRs, noting that malpractice insurers would otherwise remain free riders, benefiting from the investments of others in EHR systems through improved care and reduced claims activity.

You also must be wondering: How will the U.S. Energy Policy Act of 2005 affect HIT?  Hint: The Act shifts Daylight Savings Time from an April-November affair to a March-October one.  Well, Shahid Shah, The Healthcare IT Guy, explains everything one might need to attend to in order to ensure that HIT systems are not bolloxed up by the Act's monkeying with our clocks.  Shahid says it's not Y2K (well, neither was Y2K . . .), but forewarned is forearmed.

Despite the thrill of the national health care policy debate, some Americans were preoccupied with football this past week; Jon Coppelman at Workers' Comp Insider is no exception. He contemplates the sad case of former New England Patriots linebacker Ted Johnson and the lessons for sports medicine and workers' compensation return to work programs.

Thanks for dropping by, and be sure to check out the next edition of Health Wonk Review, to be hosted by Julie Ferguson at Workers' Comp Insider on February 22.

-- David Harlow

Commonwealth Fund report on strategies for slowing health expenditure growth

There was a brief flurry of debate over the past couple weeks concerning the Bush health plan, though that seems to have died down for the moment.  For a taste of the debate, check out the comment marathon following Matthew Holt's post on the Bush health care "plan" in the State of the Union address over at The Health Care Blog.

Whenever issues of health care cost and affordability come up, someone always notes that European countries provide better care at lower cost, and someone else always says, so what, that's not relevant, and maybe not even true. 

Well, I'll jump into the fray, but not alone -- The Commonwealth Fund's Commission for a High-Performance Health Care System released a report last month entitled Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?  The report led with a look at growth in health care costs over the past 25 years in the U.S. and in Europe -- guess who's ahead.  (Check out the graphic -- click to enlarge.) 

The summary of the report reads as follows:

The U.S. is an outlier in the level of health care spending, with far higher spending on health care per capita than other countries. There is ample evidence that the U.S. does not obtain value for money spent, and that there are wide variations in health care spending across the U.S. that do not contribute to better health outcomes.

Substantial net gains in quality at lower costs are potentially achievable from realigning payment incentives to reward efficient and high-quality care, reshaping market incentives to reward value-driven health care, improving administrative efficiency, and redesigning care delivery systems to enhance primary care. Such reforms would be founded on enhanced information about the quality and cost-effectiveness of care and appropriate deployment of modern information technology. Fragmented policies that focus on one aspect of care or shift expenditures from one payer source to another, or from one sector to another, will not result in transformation of the health care system to yield high performance.

There is a compelling need for a coherent public and private sector strategy, with all parties working in concert toward agreed-upon health system aims. Such a strategy should place high priority on policies and practices that have the potential to move our nation toward benchmark levels of performance on access, quality, and efficiency, so that the U.S. health system could achieve commensurate value for the significant resources it commands.

The report lays out some background and a framework for thinking about how to slow the growth in costs, and is worth reading.

It is human nature to like to hear from folks who agree with us -- and so I'll close by plucking out one bit of this report that I liked reading:

Again and again, studies have found that high cost-sharing, including deductibles, leads patients—particularly those with low or modest incomes—to forgo both essential and more discretionary care.

So we need a new way of thinking about this problem.  The flavor of the month seems to be value-based, or value-driven health benefit design.  Check out the discussion in the report.

-- David Harlow

Value-driven health care: Premier HQID demonstration yields improved performance, HSAs may as well -- but there's a limit to these things

CMS recently released year-end results from its "groundbreaking" CMS - Premier Hospital Quality Improvement Demonstration.

Participants in the Premier Hospital Quality Improvement Demonstration reported significant improvement in quality of care across five clinical focus areas measured by more than 30 nationally standardized and widely accepted quality indicators.

The average improvement in the project’s second year was 6.7 percentage points, for total gains of 11.8 percentage points over the project’s first two years.

There's more detail in the rest of the press release and on the Premier website.

CMS and others seem to be going ga-ga over the results, but the question needs to be asked:  Are value-based P4P initiatives really going to lead to improved health care quality across the board?  In the zero-sum game of health care financing (and it might have to be less than zero -- see earlier post on this topic), if the top two deciles in the HQID got some extra bucks, then lower-performing deciles and other provider types missed out on $8 million of CMS funding.  Does this incentivize the low performers?  Maybe.  Is enough money at stake in the aggregate to harm the low performers and drive their performance even lower?  Not yet.  Are the health care quality gains, including those occasioned by preventive care, significant enough to warrant these P4P payments?  Probably.  What happens when all deciles bunch up at the top?  That's a good thing, that's what we want to incentivize, but then the distinctions between deciles are what law professors like to call "a distinction without a difference." 

Value-driven choices include HSAs as well.  A tip of the hat to Jane Hiebert-White over at the Health Affairs Blog for posting on this issue.  She wrote yesterday:

Gaining greater clarity in exposing costs and value of health care treatments is at the heart of a new approach [2 week free access] published yesterday in Health Affairs by Harvard professor Michael Chernew and Allison Rosen and Mark Fendrick of the University of Michigan. The aim of this “value-based insurance design” is to “help patients spend their health dollar wisely.”

Another voice in favor of promoting HSA flexibility is David Gratzer of the Manhattan Institute, whose Wall Street Journal piece this week bemoaned their underutilization.

In theory, I do not doubt that HSAs can help some well-informed individual consumers save health care dollars.  I also do not doubt that, in theory, value-based insurance design may have some benefits.  However, I think we have a long row to hoe before these experiments could pay off for the population at large (in terms of both cost savings and health status improvement). 

Value-based insurance design means, largely, tiered financial obligations for consumers based on insurers' decisions about safety and/or efficacy of particular treatments or providers.  Well, tiered provider panels -- on the agenda again in the Massachusetts universal health care law; see my summary here) have never gotten off the ground in my neck of the woods (everyone wants to go to the Harvard teaching hospitals, sometimes even for the proverbial hangnail).  And moving consumers to act in their enlightened self-interest may require bigger out-of-pocket expenditures than many folks are willing to stomach (triggering a failure to access preventive health care services and thus leading to higher total costs), and a significant departure from the cost-is-no-object mindset that has pervaded the consumption of health care services.  (See this week's Washington Post op-ed piece on this subject, also cited by Jane in the same Health Affairs Blog post.)

-- David Harlow

Disruptive physicians and medical apologies

The Joint Commission (i.e., The Organization Formerly Known As JCAHO) is field-testing standards on disruptive behavior.  The working draft provides some insight into the Commission's thinking; the elements for performance to this standard are as follows:

1. The leaders develop a code of conduct that applies to everyone who works in the organization.

2. The code of conduct defines desirable and disruptive behavior.

3. All who work in the organization are educated about both desirable and disruptive behaviors.

4. The leaders develop processes for managing disruptive behavior.

5. Leaders identify the roles of individual leadership groups in managing disruptive behavior.

6. The organized medical staff manages disruptive behavior exhibited by physicians or individuals who are granted clinical privileges.

7. Leaders establish a fair hearing process for those who exhibit disruptive behavior.

While noble, the sentiments behind these standards are not brand new.  In fact, a JCAHO standard, circa 2001, touched on these same issues and was addressed, for example, by the Massachusetts Board of Registration in Medicine by promulgation of its own related policy.  Apparently the lighter touch of the earlier standards (which is sometimes extremely important in trying to deal with difficult personalities who are also brilliant clinicians) has proven to be insufficient to deal with the sometimes intransigent issue of disruptive physician behavior.

A tip of the hat to Michael Cassidy at Med Law Blog for noting the proposed standard change.

Unfortunately, disruptive physicians may also be, at times, physicians involved in medical errors.  I heard a terrific piece on NPR a while back on apologies -- exploring the question of whether apologies are a good idea, from both psychological and risk-management perspectives.  This is, of course, a hot topic these days (check out The Sorry Works Coalition).

Update 1/25/07:  A Healthy Blog posted yesterday: "Doug Wojcieszak, the founder and spokesperson for the SorryWorks! Coalition, spoke at Health Care for All about apology and disclosure following adverse medical events."  Doug's slides are up at A Healthy Blog. 

Double hat tip to Michael Cohen at CAM Law Blog (a fellow Bay State blogger) and Daniel Goldberg at The Medical Humanities Blog for highlighting Marlynn Wei's law review article in press on medical apologies (link to abstract and downloadable PDF).  The article explores whether insulation from legal liability exists under state laws out there, and whether existence of these laws promotes apologies.

Civility certainly ought to be promoted, whether through sanctioning disruptive physicians or through encouraging apologies where mistakes have been made.  Given the increasing availability of provider quality report cards and the like, and the increased ability of consumers to decide where to get their care (thanks to health savings accounts and other consumer-directed health care initiatives), civility is not simply an ethical goal, it should be recognized as a bottom-line business goal as well.

Update 4/13/07: More states are considering medical apology laws.  Check out the AP story here, which includes a discussion of laws already on the books as well.

-- David Harlow 

Health care insurance reform notes from South Carolina

Health care reform watchers here in Massachusetts are following local details as they unfold, interrupted somewhat by the changing of the guard as Patrick appointees will fill various posts now held by Romney appointees. 

Many of us follow with interest developments in other states as well (see this post and comment).  Some in the business community are concerned that the Massachusetts law goes too far in terms of imposing obligations on employers.

How refreshing it is, then, to hear from Jay Ragley, state director of the National Federation of Independent Business/South Carolina, a small-business advocacy group.  He wrote an op-ed piece, on the need for choice in health insurance for small business, that ran in yesterday's Greenville (S.C.) News.  His piece, and the comments posted on the News website taking issue with it, show that the debate is alive and well not only in MA, NJ, CA, etc., but also in states like SC, described by Ragley as needing health insurance reform and being plagued with extremely poor health status across the population at large.  I don't know anything else about the insurance market or legislative agenda in SC, but here's hoping that national engagement with these issues will have positive effects in each state.

-- David Harlow

Health Wonk Review #22 is up at MSSPNexusBlog

The latest HWR is up at MSSPNexusBlog.  I'm honored to have a HealthBlawg post in there this week.

-- David Harlow

Why haven't consumer-directed health plans taken off?

A recent study conducted by The Commonwealth Fund and the Employee Benefit Research Institute reveals that enrollment in high-deductible health plans (HDHPs) and consumer-directed health plans (CDHPs) is up this year by a meager 1%.  (Be sure to read the summary on the first page of the study report.)  One would think that the tax benefits and low premiums would sway consumers, but this has not happened in significant numbers.  This fact is bemoaned by the analysts (e.g., HFMA) and the advocates (e.g., Health Care For All).  President Bush has been pushing CDHPs as part of his program of personal responsibility (heralded at various times, including the signing of the HIT/EHR executive order back in August, as noted here), but the public isn't buying it.

Why is this so?  There are a couple of possible explanations.  Depending on which one you believe, there may be more movement over the next year.

One possible explanation is that fuller engagement with the whole idea is possible only now that the IRS has provided clarity regarding tax treatment of health savings account (HSA) contributions, and the real effects of this policy clarification will not be seen until the next plan year.  This is because most groups had already made health insurance commitments for 2007 before the IRS acted.

A related possible explanation is that the tax benefits for HSA contributions were not generous enough, and now that the lame duck Congress enacted a $1 billion giveaway in its final hours (as elucidated below), more folks will contribute to HSAs.

The boondoggle du jour is explained in today's Washington Post as follows:

Under current law, annual contributions to the accounts are limited to the amount of a person's annual insurance deductible and cannot exceed $2,700 for an individual or $5,450 for a family.

Under the new law, if it is signed by President Bush as expected, any health savings account holder could choose to shelter the maximum amount, which is scheduled to increase next year to $2,850 for individuals and $5,650 for families.

Some say that HSAs and HDHPs are working for some people, though some would say they're working best for the people who need them least (see my earlier post here, including a link to the RAND report on the subject).

Now that the IRS issues are out of the way, and Congress has made HSAs even more attractive, the financial services industry is likely to fill the void and market HSAs more aggressively.  (See Health Affairs Blog post on the subject.)  As a result, many small employers and individuals who have not been interested in HSAs to date are likely to get into the game.  Matthew Holt, who puts out The Health Care Blog, commented on that Health Affairs Blog post and seems unwilling to trust the health care - financial services cabal to do the right thing.  I share the concerns of the commenter on the post linked to above on Health Care For All's A Healthy Blog who observed that getting data on health plans and providers isn't like asking the greengrocer for information about today's produce selections.  It's not a face-to-face interaction, and the average consumer may not be able to make informed choices about health care options.  In fact, uninformed choices may have lifelong negative ramifications.

All of this leads me to the final possible answer to the question of why more people don't enroll in HDHPs and CDHPs:  Maybe they're just not a good idea.  The HSA-HDHP concept has been advanced as a political response to an economic issue.  While there is a long history in this country of dealing with health care in this fashion, perhaps this is one circumstance where we can "just say no."  Now that the lame duck Congress added a few last curveballs to the mix, it will be interesting to see whether the new Congress will be able to make sense of this morass.

-- David Harlow

Massachusetts universal health care coverage: employer perspective

I presented an introduction to the MA universal health care law a few weeks ago to a group of corporate counsel -- focusing on the employer's perspective.  My presentation was drawn in part from materials on the Massachusetts legislative website (look for "Health Care Bill" about halfway down on the left).

-- David Harlow

HSA contribution limits

Quite a few folks have come to HealthBlawg recently in search of HSA contribution limits, so I thought I'd post a link to the IRS page with HSA contribution limit and HDHP info for 2007.  If you're interested in HSAs beyond "just the facts," or in other health care law and policy issues, have a look around.

-- David Harlow