CER Hits a Snag

Comparative Effectiveness Research (CER) may have inadvertently lost credibility even before health care reform is actually launched.

CER is the darling of the government-dominated health reform movement (not a government take-over, to be clear). The use of evidence-based medicine when combined with cost-benefit analysis has the potential to save a great deal of money while better serving the patients. Many see downsides though; too rigid protocols and interference with physician judgment, or the dirty "R" word, rationing.

The U.S. Preventive Services Task Force recently released a study on various breast cancer screening modalities, recommending more limited screening protocols, particularly delaying routine mammography until age 50 (except in women with unusual risk factors).

Kah – boom!

USPSTF points out film mammography does cut mortality, with the greatest reductions in women over 50, with the best results in the age 60 – 69 cohort. Film mammography does carry a risk of false positives and the pain and inconvenience of unnecessary biopsies.

USPSTF also recommends ceasing mammography on women over 74, citing a lack of reliable evidence of reduced mortality.

There was a huge backlash from women, physicians, cancer activists and some health care associations.

USPSTF also recommends against teaching women to perform ”breast self-exam” (BSE) which has been a standard tool for decades. More backlash.

USPSTF does point out that digital and MRI mammography do not show, at this time, significant improvement over film mammography, but do have greater costs.

None of the conclusion appear to have been made on strong and startling statistics, but on think pros and cons, as one might expect from quants and scientists.

Women apparently want a little less quant and a lot more consideration.



USPSTF report:

http://www.annals.org/content/151/10/716.full

Game On!

The 1920 page House bill was passed and the 2020 page Senate bill is now subject to active debate.

Keeping up with the details is impossible, but we monitor the key points as best we can.

Game on!

HIPAA Security Alert

HIPAA Horrors

The Blade (Toledo) reports on October 28th an imaging technician was arrested in Ohio for driving infractions and possession of marijuana.

During the arrest the police scanned his cell phone.

In his phone were photos of dozens of partially clad patients preparing for imaging tests, including minors.

Wow.

The penalties and lawsuits are likely to be massive.

HIPAA Security Alert

Do you trade-in or donate used cell phones?

Before you do, you MUST scrub all of the data from the phone.

Game On!

The Senate Finance Committee is holding hearings today, likely focused on the "public option," with serious disagreement even among Democrats.

Senator Baucus has been in the lead in the Senate, but his opposition to the public plan (he thinks the plan, whatever the merits, would kill the bill) has irritated some senior members of his own party.

Stay tuned.

Reform Round 2

President Obama's speech yesterday was "hitting the reset button" for health care reform.

First impressions - the numbers do not add up.

And every President since Nixon has promised to reduce "waste, fraud and abuse" from Medicare and Medicaid.

Game on!

HIPAA Security Social Nightmares

Facebook ™, Myspace ™, Twitter ™ and millions of web logs (“blogs”) are connecting people worldwide, and that includes your employees.

Some business organizations are using these social networks, some not, but either way it is a good bet your employees are using these sites to connect with and expand their social networks.

That can be a huge problem!

Employees used to flashing every aspect of their lives on-line are very likely to discuss work on-line as well.

Social networks sites create a huge risk for HIPAA violations, and also for employee problems (some of the comments posted can be incredibly vicious),

HIPAA is 24/7!

No, you cannot control your employees lives, EXCEPT as it relates to work.

Every health care organization should develop policies and procedures on the use of social networking sites for the broadcast of work related information. Soon.

The Doomsday Scenario

So why are conservatives so excited about health care reform?

Many see the progressive left pushing a gradual move to the Doomsday Scenario, something like this:

1) private health insurance is hyper-regulated, underwriting standards are eliminated, and premium costs rise astronomically

2) employers, especially smaller employers, drop coverage and push employees to the “public plan”

3) the resulting dislocation of coverage and expansion of the public plan becomes a rationale for single payer – “see, we told you so.”


Having read thousands of pages of reform material over the past 18 months, and having studied the various reform movements since the early 90s, I think the Doomsday Scenario is quite feasible, and certainly I wouldn’t put it past the progressive left.

In public President Obama emphatically denies any such scenario. However, if the Scenario were to evolve, would he revert to his earlier ideas on single payer?

My request is for an honest debate. If Obama really wants to move to single payer, he should say so, and let the real debate begin.

For now, expect fireworks (not excusing rude behavior by the way).

Models for Reform?

President Obama often cites the Mayo Clinic and the Cleveland Clinic as models for providers in a new era of health care reform.

Question: Can these two models be replicated throughout the country?

Answer: Not likely. Certainly not in the near term.

The Mayo Clinic is unique but has replicated itself a few times, and the Cleveland Clinic is unique and to the best of our knowledge has not been replicated.

Even if these models could be replicated, it is unlikely they could be replicated in any but some urban areas. And if they could, the transition cost in most markets would be immense, and who would pay for that? (the new Mayo Clinics are in high growth and very prosperous areas, Florida and Arizona)

Can we learn anything from these clinics. Possibly yes. Can we duplicate these models in other areas? Not likely, and certainly not in the near term.

The Status of Reform

As of today, there are as many as five (5) plans active in Congress, President Obama is getting impatient, Congressional leaders are counseling patience, and no one knows if any action will be taken before the August Congressional recess.

Stay tuned.

Battle of the (Senate) Titans

Senators Kennedy (Chairman of the Senate Health, Education, Labor and Pensions Committee) and Senator Dodd (Kennedy’s wingman while he fights cancer) are seemingly lined up as opposition forces to Senator Baucus (Chairman, Senate Finance Committee ) on some aspects of health care reform legislation. Various theories are evolving:

1) this is a real dispute
2) this is a clever ruse to allow a compromise that gives political cover to all types of Democrats
3) this is just some foreplay designed to allow Kennedy to be a hero one more time, with serious cred to Baucus, a rising power in the Senate
4) some combination of #1 - #3


Kennedy and Dodd’s latest: http://dodd.senate.gov/?q=node/5062/print

Medicare Bundling

The federal government is concerned about the incidence of Medicare re-admissions.

Typical scenario: an elderly patient is admitted to the hospital for pneumonia and related distress. After a four day stay the patient is discharged to a long-term care facility.

A week later the patient is re-admitted with acute distress, after the nurse requests orders from the patient’s physician. After several days the patient is again discharged to the nursing home.

This cycle is very costly to Medicare, and the feds would like to see it slow down.

(Based on conversations with long-term care nurses and reviews of Minimum Data Set (MDS) summaries, the patients are usually very old, very frail, but not at death’s door quite yet.)

One solution is to ‘train” physicians and families not to be so quick to send the patient back to the hospital. This is tough on families, who often pressure the physician to readmit. Sometimes the patient demands readmission, it is easy for the physician to say yes. This can also be tough on the nursing home, where higher acuities are colliding with the nursing shortage.

A proposed solution is bundling. President Obama mentioned it in his 6/15 speech to the AMA. How does it work? The hospital gets a flat fee per incidence and then has to pay the physician, nursing home, ambulance/transport company, physical therapist, etc.

This requires a lot of administrative work and some intense negotiations, and puts the hospital at significant risk.

Could this work? Maybe. Is it good for Medicare? Probably yes. Good for patients? Unknown. Good for physicians? It depends. Good for the nursing home? Doubtful.

Fast and Furious

No, not the movie - health care reform.

In recent days:

• President Obama, in his Saturday radio address, promised to get hands on the issue.

• Senator Kennedy let draft reform legislation float around, creating the appearance that he is stepping in front of Senator Baucus.

• Senator Kennedy and Senator Baucus issue a statement about how well they are going to work together.

• The possible tax on health care benefits bubbles to the surface once again, as do possible taxes on sodas, beer, wine, and other sinful pleasures; other possibilities include taxes on securities dealers, life insurers and elimination of certain estate planning practices.

• President Obama lets it be known he wants to tax the rich, not working people, possibly via deduction caps (Axelrod and Goolsbee floated this trial baloon on the Sunday talking head shows).

• The House is circulating a proposal with an almost mandatory coverage rule, and penalties for anyone with the means who refuses to buy health insurance (?). All non-group policies would be channeled through a federal policy exchange. A spokesmen for Rep. Waxman made clear the circulating drafts are not the official work product of any committee.

More on this as the trial baloons become more official.

Selling Health Care Reform

President Obama is selling health care reform with the argument that we need to fix health care in order to fix the overall economy.

Economic advisor Christina Romer distributed an op-ed piece today explaining how health care reform would 1) improve family incomes, 2) enhanced GDP, 3) lower budget deficits, 4) lower unemployment, 5) provide greater health care coverage (of course) and a 6) better labor market.

Wow. This is quite a claim.

Full report: http://www.whitehouse.gov/assets/documents/CEA_Health_Care_report.pdf

Paying for Health Care Reform

President Obama’s ambitious health care reform plans may have run into an immovable object – money.

In order to move forward on his plan the President has to find and/or reallocate something on the order of a trillion dollars or so.

One means of expanding health care coverage while containing health care costs is “efficiency” a fuzzy and hard to predict concept at best, especially while expanding insurance coverage.

Other potential means are been discussed by various constituencies, in no particular order:

Taxing the rich (also discussed to solve the deficit and other problems)

Tax some or all employer-paid health care benefits

Tax soda

Tax all sorts of “sin” products

Broaden the Medicare tax base

Cut payer reimbursements, possibly offset by insuring most Americans

Create new reimbursement systems for providers, perhaps “outcomes based”

Reduce or eliminate the tax sheltering benefits of Flex Savings Arrangements (FSAs)

Alter Health Savings Accounts (HSAs)

A national value added tax (VAT) or sales tax


Accomplishing this in the midst of a nasty and deep national recession may prove to be difficult if not impossible, but it appears Congress is going to move ahead and give it a try in the next few months.

Now or Never

as reported today by the Associated Press

President Obama, on a conference call from Air Force 1 with a coalition of supporters, warned that if health care reform is not accomplished this year it may never be.

(Ed: Never is a long time .......)

Obama is trying to enlist his political organization, Organzing for America, active and engaged in the political process.

Obama is leaving the details of health care reform to Congress, apparently having learned something from the 1993 mistakes of the Clinton administration, which did an end run on Congress.

Rationing or Evidence-Based?

Medicare has decided not to pay for virtual CT colonoscopies.

Medicare does cover regular invasive colonoscopies.

The x-ray procedure is a substitute for invasive colonoscopies. It is cheaper and non-invasive, but does involve x-ray radiation.

The invasive colonoscopy allows the surgeons to excise any pre-cancerous polyps found, saving a second procedure.

If the CT colonoscopy finds pre-cancerous growths, then a regular colo must be done to excise the polyps, thus causing two procedures instead of one.

Medicare does point out that the Medicare population, almost all of whom are 65 and over, may not be a good indicator for the under-65 population. Medicare is willing to look at future data.

These are the sorts of dilemmas health insurers must wrestle with. No decision will make everyone happy.

Rationing or evidenced-based medicine? Depends on your point of view.

Tax Discussion Update

May 12, 2009 - from the AP

Senators weigh tax hikes to pay for health care

By RICARDO ALONSO-ZALDIVAR, Associated Press Writer Ricardo Alonso-zaldivar, Associated Press Writer 1 hr 12 mins ago

WASHINGTON – Senators are considering limiting — but not eliminating — the tax-free status of employer-provided health benefits to help pay for President Barack Obama's plan to provide coverage to 50 million uninsured Americans.

Finance Committee Chairman Max Baucus, D-Mont., said Tuesday that there are no easy options. Senators began grappling with how to finance guaranteed coverage, a cornerstone of Obama's plan to overhaul the health care system. Independent experts put the costs at about $1.5 trillion over 10 years......

The Great Tax Debate

Employer-paid health insurance is usually a non-taxable benefit to the employee. IRC S106.

Over the years this “loophole” has popped up in various discussions of tax fairness and expanding health care coverage.

The Obama administration has floated various trial balloons, and Senator Baucus (D. Montana), an influential player in the health care reform debate, thinks the time for change may have come.

Rep. Charles Rangel (D. New York) a veteran representative and powerful chairman of the House Ways and Means Committee says simply, “no way.” All tax legislation originates in Ways and Means.

Candidate Obama criticized John McCain for proposing the taxation of health insurance benefits, but advisors to President Obama will not close the door, including new DHHS secretary Sebelius.

President Obama needs a major funding source to help close the deficit and to provide a $600M plus health care reserve fund.

Some labor unions fiercely defend the tax break, as middle class union members would be hit hard by a tax on health insurance benefits.

(Using real tax family returns and creating pro formas by adding policy amounts, the tax increase could range from about $1500 - $5000, depending on the structure of the tax, the possible applicability of FICA and Medicare taxes, and the taxation policies of state and local governments.)

In theory, employers would save some money because enhanced government programs would slow or eliminate “cost shifting” from the uninsured to the insured. However, employers might end up paying higher matching FICA taxes. Employees would be unlikely to see any of the savings (if any).

This could be a nasty debate, with some strange bedfellows.

Electronic Medical Records Held for Ransom

A drama is playing out in Virginia as computer hackers claim to have hacked a data base used to monitor patients for prescription drug abuse.

The hackers are demanding a $10 million ransom for the data, or the data goes on the internet.

Virginia health officials and the FBI believe the threat may be credible.

The future of EMR?