No Ads on Google Health? How Do They Make Money?

Here's how.

Bring Back Managed Care to Revive Massachusetts Plan

Align incentives to reward people for keeping patients healthy?

Capitation?

Really?

Duh.

Medicare Advantage Plan Spending

"Of the monthly per-beneficiary payments to MA plans, 87% is used for medical expenses, or $683 of $783 per beneficiary per month, according to the report. About 9%, or $71 per beneficiary per month, is used for nonmedical expenses, including administration, marketing and sales. About 4%, or $30, is considered profit, the report found."

Read the Kaiser Daily Policy Report here.

Let's Just Kill the OB's

Can you frickin' believe this?

They want to raise ob malpractice premiums even more in NY?

Oh Shit. Bad News for Health Care Finance. Worse News for Health Status and Homelessness

Two graphs, one depicting trends in earnings, and another showing trends in housing prices, just might hint at what's in store...

(Never mind the fact that these folks are on a runaway freight train to homelessness and piss poor health status.)

10 Out of 10 Pain?

10 out of 10 pain apparently means different things to different people.

Suckered by the "Popes of Cardiology"--LDL is Bullshit?

Have we been suckered by the "Popes of Cardiology" (who have also made a bundle of cash in the process)?

Could it really be true that LDL cholesterol is bullshit? That LDL values should be ignored?

I just read two kick-ass posts from Maggie Mahar at Health Beat.

Check out The Cholesterol Con Part I and Part II.

Yes. Health Care IS a Dysfunctional Market.

Yeah, yeah. We know health care is a dysfunctional market.

The consumer doesn't know the cost (or quality, or value) of the services they receive. They're also distanced from directly paying for the services. Physicians, nurses, attorneys, and everyone else attached to this dysfunctional system, in general, can waste resources without an immediate direct impact.

Of course, we know that this is a huge reason for overspending in health care.

Now stop fucking whining and do something about it. All the whining is boring the shit out of me. All of my own whining is boring the shit out of me, for that matter.

Skin Color is Often the Most Important Predictor of Survival

RWJF on Thursday released a report that looked at how education, income, race and ethnicity play a role in health. Findings include:

• Blacks are more likely than whites to die from many health conditions, such as diabetes, heart disease and cancer (Hille, Washington Examiner, 2/29);
• Residents who have not graduated from high school are more than four times as likely to have poor or fair health than college graduates;
• College graduates on average live five years longer than residents who do not graduate from high school;
• Higher-income residents on average live two years longer than middle-income individuals; and
• About one in three lower-income residents has a chronic disease, compared with about one in 10 higher-income residents.

Warning to Medicare Advantage Plans: Watch Out!

Looks like CMS and Pete Stark have these plans in the cross-hairs.

It's true that the FFS/PPO versions of these plans have much higher costs (and much higher profit margins for health plans). I just hope that the more tightly managed HMO versions don't get hit.

Death Most Likely Outcome of a Code. Same at 30,000 Feet.

We know that if you code, the odds are against you.

Seriously, the survival rates for when a patient's heart stops in a hospital suck.

What the hell do you think the stats will show when it happens on an airline at 30,000 feet?

Screw it, let's just sue the airline when the inevitable death occurs.

Our society has such frickin' unrealistic expectations. Sheesh.

I Love to Menstruate, Don't You?

Check out Annuale, the new oral contraceptive that allows for once-a-year menstruation.

Nader and Single-Payer

Yes, he's running again.

And he's very clear about differentiating himself from the other candidates via his support for single-payer heath care.

Google Health and Cleveland Clinic--Hell Yeah!

Google and Cleveland Clinic are teaming up to create a personal health record (PHR) quicker than anyone else could hope.

PHR's from our perspective are very important.  The fact they are patient-centric is huge.  The fact that they are portable and can be viewed outside of the walls of just one clinic is extremely valuable, and ultimately saves lives by reducing the likelihood for medical error.

(If you live in Cleveland and, by chance, are somehow rendered unconscious and taken to an ER in Lincoln, Nebraska, the fact that the physician can access your information completely dramatically increases the likelihood that you'll survive.)

We've had the technology to do this for a long time, but so many people haven't had the balls to move forward.  These companies have been fearful of the potential problems associated with HIPAA, and have either chosen to rack up legal fees in the process of creating a watered-down version of their initial idea, or have abandoned the idea completely.

Google has balls.  And although I didn't realize it, Cleveland Clinic seems to have balls too.

I like it.  

HIPAA hasn't been tested in this fashion.  When a law is created, it's also important to test the legislation based on real-world scenarios.

Do something remarkable, and worry about the impact later.  This is an idea that kicks ass, that is revolutionary, and that is in the best interest of all of us.

Privacy is important, but not to the degree that people get hurt.

More commentary on The Health Care Blog...

Single-Payer versus Universal Health Care--Graham vs Porter/Teisberg

Single-payer options have a lot of merit, from both an economic standpoint and from the standpoint of moving towards a healthier society.

Check out this fantastic single-payer animation (which apparently was done by a doc while still in school).

My only adaptation of a single-payer approach would be that any such approach much ensure adequate competition, as discussed in more detail by Michael Porter and Elizabeth Olmstead Teisberg in their book Redefining Health Care.

In their book, the authors do conclude that traditional single-payer approaches can't/won't solve our problems, but state that the reasons for this are based on the assumption that a single-payer solution will eliminate competition as it has in other countries.  My take is that single-payer health reform and competition are not mutually exclusive.  We have an opportunity to learn from the weaknesses in other single-payer systems, and have experience from the polar opposite to design a "single-payer 2.0" option.

However you feel about single-payer, the authors provide a very nice and very thorough description of why universal coverage is essential to solve our problems. 

Homeopathy is a Fraud...Like Cures Like? WTF?!!

Homeopathy can't cure HIV.

It's a shame that insufficient access to legitimate care is leading people in Africa to seek care from homeopathy.

It's criminal, deceitful, and downright sinister.

(Homeopathy can't cure anything, by the way. It's all bullshit designed to milk money out of people when they are most desperate by relying on the placebo effect. Fuck them, and fuck everything they stand for, the unethical bastards).

Coverage without Access is Meaningless-Gov Crist Proposal Falls Short

Like I've said before, you can expand coverage to win points with your supporters and to get elected.

Medicaid provides coverage. But nobody wants to accept Medicaid...they can't survive if they do.

Nobody is talking about reimbursement rates and how mandated coverage will affect these rates.

Governor Crist's plans are no different.

What a Fuckin' Shame...Katrina Still Haunts Us

Katrina's a fuckin' bitch.

Katrina was and continues to be a bitch.

But it goes beyond the initial death and destruction she caused.

She surfaced issues about race, about corruption, about choices in federal spending (or underspending), about media lies, about the facade that makes us think we're safe and protected by our government....and of course health care.

Mental health issues, stigmatized and under-treated, carry huge cost and societal burdens. And mental health has been underfunded (and has also had shameful access) for a long time.

This has been true for a long time, and it's also very true (magnified 10x) in New Orleans.

Bitch. I wish I could have ignored the problem...

Strong women get a bad rap. They raise issues that the rest of society doesn't want to deal with. They take a stand. They are accused of being unwomanly. And they know their shit. And society calls them "bitches".

Let's fucking listen for a change.

Clinton vs. Obama

Screw mandates....they don't work for a lot of reasons.

But in this brief Clinton vs. Obama excerpt, she's right from an economic/actuarial standpoint (and a health care spending standpoint) on what happens when not everyone participates.

You get adverse selection that hurts everyone that does.

Tying Pharma Rep Income to Outcomes?

Could it actually happen that pharmaceutical rep income will one day be tied to patient outcomes or health status within a territory?

Suck It, Health Net: No More Retro Cancellations

Looks like the recent $9 million decision against HealthNet (which was no where near a prior $89 million decision) was enough to get the CEO to declare that they'd be stopping retroactive cancellations immediately.

Good outcome, and right thing to do from an ethical/integrity standpoint. If you accept that our society has made a choice to opt for for-profit health care coverage, it still doesn't mean that those for-profit entities don't have to abide by commonly accepted business ethics.

If I enter into a "bad deal" as a company because I've not scrutinized the deal properly (e.g., shoddy underwriting in this case, one could say), then you have to live with the outcome of your decision. Changing the rules later flies in the face of business ethics.

You can bet, however, that they're going to tighten up their underwriting process a whole lot at the same time, and that it'll be a lot harder to get coverage.

My Point: Before we all rejoice in this decision, however, count on the fact that HealthNet will be tightening up their underwriting mechanisms a lot...and fewer people will be covered as they are deemed to be a "bad deal" business-wise.

Natural outcome for a for-profit process.

Want to Combat Retail Clinics? Strike While the Iron's Hot!

The public is still testing the waters on retail clinics.

I can't blame them. "Rollback Prices" are great, but what about when they apply to your health?

In any case, this WSJ article reinforces the fact that the timing may be just perfect for physicians to reinforce their differentiation. (Beyond "we get more than 2 weeks of anatomy"!)

It's actually probably worth a small premium...creative scheduling in traditional primary care practices to offer extended hours, combined with clear & concise pricing brochures could be all it takes.

In any case, just remember that timing counts.

Arrgh! Fuck the RUC!

More on this bitch of an organization from Kevin, M.D.

Read the full piece on the RUC in Family Practice Management here.

Do you think 5 caths (assuming they are actually necessary) should be equal to 80 99214's?

Canadian Health Care Has Too Little Rationing

Canadian health care is not socialized medicine (as I've said before).

It's a single payer system in which there is too little regulation.

In fact, based on my experience in both systems, there is a lot more rationing in our private-based health system. We've got formularies, prior authorizations, referral management, utilization management, tiered copayments, deductibles, different costs for in- and out-of-network utilization.

The Canadian system doesn't have most of that.

Until now. Quebec is considering instituting a co-payment. I think the time is ready for a change in the Canadian constitution to allow for even a nominal co-pay (I actually was surprised to see the $25 amount proposed).

Quebec actually does better in terms of utilization than other provinces.

Just imagine what takes place in provinces such as Newfoundland or New Brunswick, and what would happen if a co-pay were introduced!

In any case, just realize that the Canadian system has problems, but these are actually due to the lack of sufficiently aggressive resource management.

I feel the need to pound it into people's heads that this is not an issue of the system being socialized, nor is it a matter of the system needing the $25 to directly offset costs. It's more to reduce unnecessary utilization.

Natural evolution. They'll do well with this.

More Fucking with the Candidates...Just 'Cause

In the mood to fuck with 'em? Just read this kick-ass WSJ op-ed piece.

More Cardiac Arrest Deaths at Night & Weekends

You are 18% less likely to survive a cardiac arrest in a hospital if it occurs on a night or a weekend. Huh.

I'll make sure I don't.

How Physicians are Paid: More on the SGR Problem

Check this out....another post on the problems with the sustainable growth rate formula used by Medicare.

I'd definitely take your time reading this because it's great insight into how physicians are paid, how the SGR creates incentives for the wrong things, and how to fix it.

The Biggest Predictor of Longevity Is....

Race.

Ask Don Berwick.

Now the a report from the American Cancer Society says the same.

It's more than economic factors, since the same pattern is seen in insured minorities versus insured caucasians.

No...racism doesn't exist anymore.

How to Really Keep Health Care Costs Down

Health care is apparently cheaper if you just let the poor bastards die...especially the smokers and the obese.

We should applaud them. If you choose bad habits, after all, it's better for the rest of us because you die faster. Hell, let's give them free cigarettes, beer, and sausage....unlimited.

What a great fucking strategy.

Sick people cost less because they don't live as long. So if we convert this to an equation and solve to maximize variable X, where X = health care savings, we're better off just letting people die sooner.

Clap.....Clap....Clap.....

BRAVO!

These Dutch researchers are so frickin' brilliant!

Seriously, though, I wonder if the same would be true in the US, where we actually ramp up resource utilization exponentially in the last 6 months!

"Do More Harm": The Trends at the End of Life

A friend of ours found out their dog had severe osteoarthritis of the hip. The vet suggested that he could either give the dog a hip replacement (at a cost of approximately $5,000) or euthanise the animal for a much lower cost. Our friend really loved his dog, so he opted for the surgery.

The dog actually recovered pretty well initially. It appeared the pain was manageable, and the dog was starting to move around more easily. A week later, however, the dog was acting listless and appeared to be breathing rapidly.

Our friend took the dog to the vet, and the dog was diagnosed with pneumonia requiring treatment with IV antibiotics and another inpatient kennel stay.

The cost of this stay, including x-rays, etc. was about $800.

The dog went home, and had diarrhea everywhere. It quickly became dehydrated and died.

Was suffering, multiple hospitalizations, and ultimately death...with a lot of expense for the owner...ultimately worth it?

Our friend was paying for the bills out-of-pocket, of course. What about if someone else were paying for it?

It has been said that the majority of an individual's health care costs are spent in the last six months of life. It has also been said that this doesn't correlate with a better quality of life during this time.

If this is all true, why don't we have the guts to talk about it?

Time to Fuck with the Candidates...Because It's Our Job

When I woke up this morning, I knew it would be a great day to fuck with the candidates.

The candidates are getting more detailed in what they're willing to share in terms of health care reform.

For both democratic candidates, reform is a priority "...with the stated goal of providing coverage for everyone."  Yeah, yeah.  We get it.  I like it.  But is anyone thinking about funding?  Everyone wants to maximize their share of the health pie.  What happens to access if we don't have any statement about funding and how primary care reimburesements will have to increase?  (What about rationing?  If anyone has a way to do this without rationing, I'd love to hear it!)

The republican candidates want reform too (if you don't, you won't get elected). If we just make health care more affordable for the uninsured by providing "...subsidies to help people with modest incomes buy health insurance." Yeah, like that's going to change spending patterns. We know that people tend to decline coverage options via their employer if it involves even modest outlays--it's because they're deciding about covering costs of living and making mortgage payements. You can't blame them for making the same choice. So this solution is worthless (mandates don't work, either, by the way).  

Huckabee's just a fucking joke when it comes to healthcare....the article I linked to just sugar coats it.

The biggest potential challenge with all ideas is that unless everyone has to participate in the same risk pool, (or at least in geographically distributed risk pools that each require everyone to participate), then there will always be selection bias.  Sicker and "less desirable" patients from the standpoint of impact on medical loss ratio will have no choice but to migrate to these defaults.  The healthier (wealthier? white?) individuals will also self-select.  Anyone who thinks you can manage a risk pool with having sufficient healthy patients (low-utilizers) in the pool is smoking crack.

Regarding the republican candidates' proposals, how the hell can you decrease insurance industry regulations and also ensure that selection bias doesn't take place in terms of who's "insurable" and who's not?  The "who's not" category would be less profitable, and thus less insurable.  Even if you don't link premiums to health status, there are clearly ways around this.

Regarding McCain's tax credits, $2,500 for an individual and $5,000 for a family won't cut it.  Seriously, $5,000 for a family?  As it currently stands, my family would burn that up in 6 months (I contribute a portion to my employer's coverage).

Pessimistic...yes.  I think there's still a very large commitment to the future success of the health insurance industry.

"The candidates also have largely sidestepped the hard choices and tradeoffs that many economists contend will need to be part of any significant health care reform.

That includes the pending fiscal collapse of Medicare, projected to be insolvent by 2019."

In any case, I'm definitely glad that health care is taking center stage in this election.  I'm also glad that the candidates are getting to a level of detail that can lead to good debate.

But just in case you were wondering, I think we're fucked for a little (?) while.  Not enough pain yet to motivate action.

The FDA Struggles: More Proof that You Get What You Pay For

The FDA is taking lots of heat these days. Yes, it's because they screw up a lot.

But before you go pointing fingers, just take a minute to remember that budgetary choices have unintended consequences.

The strain of the ongoing war in Iraq has led to cuts in a lot of areas, and the FDA also got hit hard. Unintended consequences--they approve the wrong plant in China, not to mention the stumbles around drug safety and approval.

Just realize that there will be much bigger unintended consequences of the proposed cuts in healthcare over the next few years?

You get what you pay for.

Drug Seeker Stories...and a Vagina Story for Kicks

I always wonder why docs get so worked-up by drug-seekers.

Why not just fuck with 'em by being honest and direct?

(For the non-physician readers, we really do get these stories--so often, in fact, that it's hard to remember them all. We do want them to get better, but the first step (seriously) is to confront them on the lies they tell others and themselves.)

Never mind the misuse of resources....PandaBear is an ER doc, remember.

Health Care Competiton in The Simpsons

So, I started this post just looking for a picture of my hero, Dr. Nick Riviera.

But in the process, I found and learned so much more.

In an insightful piece published in the Canadian Medical Association Journal in 1998, two physicians analyze the medical care received by Homer J. Simpson and his family.

Which is the better physician, in terms of balancing cost and quality, Nick Riviera, or Dr. Julius Hibbert?

Oh, who the fuck am I kidding?! I don't care. Dr. Nick kicks ass.

Read the CMAJ article comparing these two physicians for the Simpson family here.

Got Weed? ACP Statement on Medical Marijuana

The ACP made a pretty strong statement regarding its position on medical marijuana, and debunked a number of myths and misperceptions at the same time.

Happy Ending to OHRP Checklist Story

The "....ragtag band of committed clinicians and other quality improvers..." has made a difference in changing policy in the OHRP regarding the use of checklists....says Bob Wachter.


Blog on.

Raise hell.

Do something.

Food Safety? Another Beef Recall!

What the fuck is going on with the safety of our food...particularly meat?

I'm not a vegetarian, but I can't believe how often we hear about beef recalls related to safety problems in slaughterhouses.

In this most recent case--the largest beef recall in history--potentially ill animals were not reported to the veterinarian, once initial inspection was passed.

Yes, there are process failures. Whenever a process fails, it's important to look at the contributing factors. Is it greed? Or is it that economic incentives in the industry are similar to what many physicians (especially in primary care) are having to do by increasing volume to make ends meet? We tell our docs upon hire that about 25 patients/day is what it takes to break-even at most of our locations. We've got some docs that see an average of 40 patients/day due to the fact that they've got some pretty significant personal financial stress going on.

Modifying incentives to avoid "cutting corners" is absolutely essential for us.

As far as the incentives in this beef recall case go, it appears it's too late, however, since much of this meat in question has likely been consumed I by now.

Oops.

Insurance Companies: No Business Argument for Quality

In a recent article, Ezra Klein says it like it is regarding why it would be poor business for insurers to compete on value:

1.  When we want insurance, we go through an underwriting process.  What's really happening here is that the insurer is trying to evaluate the value of "the deal".  They want to, like any rationally-operating business, secure profitable clients, and avoid those that are unprofitable.  

2.  Don't get pissed off.  Or do.  I don't really care.  The issue is that this is what you get when you throw healthcare coverage completely to the private market.  It must operate effectively as any other business would in this environment.

3.  Good quality in managing chronic diseases may actually end up attracting more of the "less profitable" type of customer--those that use more resources than those that don't have the disease state.  Bad business deal.

4.  In addition, the more sick people you insure, the more healthy people you need to offset this.  But in order to insure these sick people, you also have to raise premiums.  Raising premiums will ultimately scare away the healthy and more profitable patients.

In this structure, there isn't a business argument for quality.  

Ezra Klein's article also discusses some ways to get around this--avoid risk-pool selection bias, acuity-adjust funding (such as in Medicare Advantage), etc.

AMA Banned from Hearings: I Don't Care

Here's the deal.  The AMA has been banned from the hearings dealing with the impending 10.1% Medicare cuts will happen or not.  Apparently, they've just pissed people off.

I don't care.  I've always felt the AMA sucks ass, and that it could never adequately represent me and my colleagues.  In fact, if they were involved in these hearings, I still believe that they more strongly represent subspecialists.  

The AAFP and ACP got it covered, among a number of other good organizations.

With that said, I really hope they can achieve a complete formula fix instead of another patch. 

God help everyone on Medicare if they don't.

Does Preventive Care Save Money?

OK, the perspectives piece "Does Preventive Care Save Money? Health Economics and the Presidential Candidates" does raise an interesting question. 

In this case, the authors have raised the question based on the hypothesis that the statements and claims being made presidential candidates are perhaps a bit too broad.

Maybe.  I actually think this was a pretty crappy article overall...I get the point.  But it really trashes prevention in the areas where there are huge savings (brushing over the economic impact of some high-impact USPTF recommendations).  I also think it doesn't go far enough in telling the hard truth for docs and the public:

• Not all "screening tests" currently in use meet the criteria for ideal screening tests.  
• Screening tests should be use appropriately.  The authors say that "...screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures."  Well, then, this doesn't quite meet the criteria for the ideal screening test.  The 80-year-old man doesn't need a PSA, and his wife doesn't need a pap smear.  Similarly, people shouldn't be ordering CA-125 tests for women to screen for ovarian cancer.  Strap on some balls, and tell your patient they don't need the tests.
• The public tends to think we have the ability to detect anything early and cheat death if it's caught early.  As a society, we need to get a grip on our mortality, and on what is and is not possible.
  
• The concierge physical market isn't doing any favors here.  Lots of high-cost tests without proven outcomes set the expectations for all patients that they need these things when, in fact, they may actually cause harm
  
• People need to be clear on the definitions of primary care and prevention.  Yes, prevention is part of what we do.  But it's not just prevention of heart disease, it's also prevention of the avoidable ER visit or hospitalization.  Access to primary care is clearly tied to reductions in these areas.
  
• Everyone is dancing around the fact that we'll have to ration resources more.  No, Mr. Johnson, you can't get a fucking MRI for your back given your symptoms.  And no, you can't fucking sue me for saying so.  (OK, so the candidates are just trying to get into office right now...but someone's got to be saying it!)

The authors actually provide some misleading information.  Although they didn't list the 279 preventive measures that they refer to, the authors do present some of the measures used in their tables.  The quality of some of the studies used for the analysis is really shoddy.  Take the "high" versus "low" intensity smoking relapse-prevention programs, for example.  The high intensity program sent 7 mailings to patients, while the low intensity approach sent one single booklet.  First of all, neither approach works that well!  If it were to be compared to a more effective approach (regular access with a primary care physician, support groups, etc.), I wonder if the results would be different.

And screening for medium chain acyl-coenzyme A dehydrogenase deficiency in newborns?  Since when is that a useful screening test worthy (in terms of ideal screening test criteria) of application to all patients?  I think the real issue here is that when it comes to babies, people have a real hard time rationing care (not to mention the medico-legal pressures).

It's not a horrible article.  It raises a point.  But don't fucking dance around the issues.  This is a perspectives piece, and some leeway is allowed.  We're not doing the public any service by sugar-coating the real issues.  

More on SGR...and How It Contributes to Growing Disparity Between Specialist and Primary Care Reimbursement

From the Health Affairs Blog..."Splitting the Sustainable Growth Rate..."

"...Lost in this debate is an appreciation of how the SGR approach has contributed to a large and widening gap in earnings between specialists and primary care physicians, an income gap that is a major contributor to the dwindling number of physicians entering careers in primary care, putting the foundation of the American health care system at risk...."

Yes.  We've argued about whether or not this pay differential is real and whether it's justified.  And primary care physicians (like me) continue to be pissed.  Fuck everyone.

Well, I think this author does a great job of analysis, as well as recommending a logical and feasible solution.

I'd love to know what I'm missing here....would it put specialists at more risk?  Fuck yeah.  But the same would apply to PCP's.

Fair.

Choking Your Chicken is OK....Not Your Neck!

Kids, especially boys, are apparently enjoying the near-suffocation experience of self-strangulation.  Honestly, I'd rather have my kid smoking pot.

Classic comment in the category of "warning signs" from the CDC:

• "A thud in the bedroom or against a wall."

So....watch out for a "thud".

Thud bad.

Is United Healthcare Overcharging for Out-of-Network Services?

NY State Attorney General Andrew Cuomo is going after United Healthcare for allegedly overcharging patients that receive out-of-network services.

An interesting question is raised here.

The principles are as follows:

1.  You get healthcare at a better rate via a group.

2.  The better rate is possible because the actuarial risk is shared across more people (and more premium dollars).  In addition, the rate is possible because the in-network folks have agreed to accept certain rates and to abide by certain guidelines.

3.  Out-of-network services, thus, take advantage of the concessions made by others.  The costs are higher precisely because they are unmanaged.

4.  Excessive out-of-network utilization makes it impossible for the health plan (government or private) to keep premiums low and affordable.  It also makes it difficult to recruit physicians to be in-network providers.

So, the deal is this.  Cuomo alleges that the health plans are charging patients the difference between the out-of-network cost and the "usual and customary" costs, and that by understating these "usual and customary" costs, is overcharging patients.

If I were on the health plan side of this, I'd be wondering whether he really cared about affordability.

From a patient perspective, I'd just want to things to be transparent...what's the cost if I use an OON provider?  

I personally don't have a problem with penalties for OON utilization.  If you rape the system, then you should pay up to offset the pain you inflict on the rest of us.

But if the penalties are over-stated in order to build in a % profit margin, then I've got a huge problem.

Medicare Advantage Plans are not All the Same

There's a lot of pressure on Medicare Advantage plans.

Lots of people see a substantial amount of subsidization for these plans.

In fact, a bunch of these MA plans were instructed to halt all marketing activities last year, based on the finding that the costs of those plans was significantly higher.

It's worth looking closer here.

The Medicare Advantage FFS plans are actually the plans with the higher costs, as they really aren't managed tightly.  The MA plans that have been managed via risk-sharing (capitated) arrangements have demonstrated approximately 19% lower costs.

These plans are not all the same, and legislative approaches must recognize this fact.  

MA plans are not all the same, and it would be a shame for the plans that have risk-sharing contracts to be lumped in with the PPO plans.  The risk arrangements produce better outcomes at lower costs precisely because the primary care physicians are taking the risk, and are thus rewarded/penalized for their ability to truly coordinate care.

Don't kill this.   

Medicare Goes Broke, Bush Must Fix Problem

Doooh!

It looks like a "trigger" has been tripped that requires El Presidente Bush to fix the issue of excess Medicare costs.

So, he's now got to provide a legislated plan (post budget) to achieve Medicare savings.

HHS Secretary Mike Leavitt:

"...Leavitt suggested that the proposal would be in line with the administration's beliefs that health care should be a "private market where consumers choose, where insurance plans compete and where innovation drives the quality of health care up and may drive the cost down." He added that the competing vision of health care is a "Washington-run, government-owned plan, where government makes the choices, sets the prices and [then] taxes people to pay the bill." Leavitt said Bush likely would have the proposal to Congress before Feb. 21..."

Hint for dumb-ass:  Health care doesn't function as a private market right now, and consumers don't really choose (and if they were to really choose, they don't have the information needed to make the educated purchasing decisions essential for healthy markets).

Leavitt suggests an either-or approach.  What about a new choice...a blend between private and government-run?  

McGill University & House

Yes.

It's true.

Health Punk is a McGill alumnus.  Faculty of Medicine.  

So, whether or not you like the show, "House, M.D." should really be "House, M.D., C.M."

And whether or not you like the show, and for the non-Canadians reading this, McGill is and will always be better than University of Toronto. 

More Cost-Shifting

More cost-shifting adaptations in NYC emergency departments.

Too bad that the bigger issue is that many patients shouldn't end up in the ED anyway.  If only there were primary care incentives to help.

Transparency...No, Secrecy...No, Transparency...Oh., Screw It

Secretary Leavitt seems a tad bit inconsistent on HHS's stance on sharing CMS data.

I think transparency is good.  But it's only good if everyone is fully transparent (or admits that they aren't).

More on the SGR and RBRVS

Yes.  It's boring.

But it's important to your reimbursement and to your viability.  It's also important to the health of our communities.

Suck it up and read the next installment from Health Affairs on SGR and RBRVS.

Your mom will be proud.  Maybe you'll get a hug or something.

Back Pain and the Money Whores

The anesthesiologist, now pain management specialist (a.k.a., "the block jock") doesn't care about controlling your pain unless it involves sticking a needle in you. They love doing this shit (even though a monkey could do it just as well).

I had a patient who received a block in an area that didn't even correspond to her pain (but, then again, I can't blame the block jock--why the fuck should he bother to take a history, when there's no money in it?).

Back pain is a huge fucking problem for society, and lots of people are lined up to make a buck on it whether or not there's evidence for their intervention. The orthopedic-trained spine guys are particularly notorious. Yeah, it's a generalization, but prove me wrong if you don't like it.

A big part of my job is protecting my patients from these money whores.

We all know that the patients don't get better, so who the fuck are you trying to kid?

Shit, in our area, these guys don't even bother to send consult notes back to the referring physician (assuming the patient was really referred).

It's a huge vortex that sucks money. In our situation, it also takes it out of the pockets of the primary care physicians in one of our more important capitated contracts.

So, for the anesthesiologists, the physiatrists, and the spine docs that operate or intervene on a whim, here's a big "fuck you" from the rest of us, and from the patients you harm.

Read some fucking evidence for once.

P.S.--It looks like the lay media's on to you...check out the NY Times blog on rising back pain costs.

Health Care and 2008 Candidates: Summary of Positions

Here's a great resource for understanding where the candidates in this election year stand on health care issues, with side-by-side comparisons of their plans, from the Kaiser Foundation.

Major Medicare Reform & Sustainable Growth Rate: Everything You Want to Know

Paul Ginsburg speaks the truth. This is a great summary of the history of Medicare's sustainable growth rate for anyone serious about this stuff.

Not for the faint of heart....or the hopelessly stupid, for that matter.

Primary Care Must Be Central in Health Care Reform

Props to Kevin: "Primary Care is Damn Cheap and Can Solve Our Health Care Woes"

Immigrant Workers Don't Hurt the Health System

Do people realize that in order to both fund the health care costs of an aging population and to offset the shared actuarial risk for the US population, we need more young and healthy workers?

Immigrant workers will not have a significant impact on increasing health care costs, as this Kaiser Foundation report states.

In fact, they'll actually be helping.

If you're against this, I sure hope you've got money to help pay for your own costs. If they paid for their own, their actuarial risk would be lower, and they'd actually get a better deal.

What pisses me off the most (beyond just immigration issues and health care) is that I think that there are a lot of latent racists that use these issues to justify or re-route their deeper sentiments.

Racial Disparities in Health Care--Having Coverage Isn't Enough

Having coverage isn't enough to eliminate racial disparities in health care. A racial disparities study seeks to dig deeper.

Consumerism Lower Health Care Costs? Right.

From Health Beat, regarding a study on whether consumerism can actually lower health care costs:

"...Research by the RAND Corporation’s health insurance experiment shows that when you shift costs to the consumer, patients forego both wasteful and effective care. And this is particularly true of the patients who cost us most in the long run—those suffering from chronic diseases..."

Of course, if you don't get the preventive care or chronic disease management you need, you'll cost the system a shit load more.

Physicians as Secret Agents--Is Your Information Safe?

What a fucking fiasco. You've got to read this article about Blue Cross of California's request to have have docs help them in dropping patients.

Here's the deal. Wellpoint (owners of Blue Cross of California) has sent a request out to primary care physicians to pro-actively review the charts of patients and to forward on any information that may indicate a pre-existing condition that was not disclosed by the patient. They want the docs to take time to review records, but more importantly, to review the information of new enrollees.

Of course, it's to help them find a reason to drop patients from coverage.

My issues with this:

• Since when does the primary care doc become the tool for enforcement? Fuck this. Can you imagine what it does to the physician-patient relationship? Would you want to reveal everything to your doc if you knew they might report it to your insurer?
  
• We as primary care physicians get shit like this everyday....we're asked to audit charts and complete forms to help the health plan comply with HEDIS reporting requirements, to help them keep their costs down, to help them achieve "marketable" outcomes. Of course, paying for our time is out of the question, as is sharing the benefit of achieving these results. Again, fuck this. Civil disobedience by either invoicing them (if the contract allows) or by shredding / burning the requests sounds like a good idea.

The morons in the PR department are gonna get what's coming to them. They're trying to say that they're doing this to help out the large medical groups--but it doesn't take a rocket scientist to know that the new enrollees' information isn't with the new PCP, but rather the old one!

Fuckin' idiots.

Even if you paid primary care docs to do this shit, they wouldn't ethically do it.

Good post at The Health Care Blog on this too.

A Medical Home Costs Money

A medical home is a great concept, and it's right in line with the true role of primary care.

It's also going to take money to do it right....most of the work involved is not compensated currently.

Here's an article about a Medicaid pilot program in Illinois that pays $2 pmpm (per member, per month) for the service.

Bite me.

OK, I do want to be fair--this is most definitely a step in the right direction. But for it to be meaningful, it also depends on having a substantial number of "members" (Medicaid recipients as patients). And as everyone knows, the larger the percentage of your payer mix that is Medicaid, the less solvent your practice becomes.

Not to mention the fact that the other payers need to also pay their fair share...is this doc going to provide medical home services to some but not other patients? It's a logistical nightmare.

So right direction, good intent, but still "kinda pitchy dog....no to Hollywoood".

Myth-Busting Canadian Healthcare--It's Not Friggin' Socialized Medicine!

Here's a great post (from a while back) on Maggie Mahar's blog. The post does a nice job of "myth busting" Canadian health care.

(For those of you who tend to criticize, whine, and fear-monger without knowing shit--see my prior post).

Canadian Health Care: Don't Criticize What You Don't Understand

OK. I've had it. I'm sick and tired of people bagging the Canadian health system when they have no fucking idea how the system works.

And yes, I do know how it works. I think my background in health systems management and public health, my experience working in both systems, and the fact that part of my family lives there and receives care there as patients gives me a bit more insight than the other bastards that spew off criticism about shit they don't understand.

"You have no control, you can't see who you want, you'll die on a wait list...." and so on. All bullshit. But it makes for the sort of great fear-mongering for our political machine....

To be fair, I really don't know if Kevin, MD feels this way about the Canadian system, but he did choose to point out that "...it looks like the grass is not always greener..." in the Canadian system.

No, the grass is never always greener. But sometimes, it looks pretty damn good. You know, in order to get really green grass, you sometimes need to put up with some shit and fertilizer in your lawn. Suck it up. They live longer than we do, and they don't go bankrupt because of health care expenses.

In any case, here's my retort, also posted in comments on the site:

Don't bag the Canadian system with a blanket statement. I'm an American doc that has experience in both. The propaganda does no one any good.

No, it's not perfect there. But the grass, from the perspective of public health, is a whole lot greener.

It would be a flaw in reasoning to attribute the problems they face with the sole fact that they have a single payer system.

1. They need more controls around utilization (we actually have much tighter regs via managed care in this country), and could use greater efforts in disease management, etc. They do need copayments, guidelines, etc.

2. The single payer component actually reduces overhead and improves accounts recivable significantly.

3. They have much less med school debt (if any).

4. They have much lower malpractice costs.

5. One can't generalize, as the problems differ by province (as does the way in which physicians are paid)...the provincial governments that have implemented salary caps for primary care physicians are insane.

6. Some provinces face a problem with churning by physicians, over-referral, over-utilization to feed the churning beast (downstream churning to specialists, etc.)

7. My take is that there is too much choice and too much freedom in the Canadian system, and that tighter controls and true management of care (cost & value) is what's necessary. I also think competition needs to be amped up.

Too much freedom and too little "management" of care with skewed incentives (again insufficient rewards for primary care docs to manage care and to manage populations) are the issue....NOT the single-payer methodology alone.

This is The End...for You, My Friend

Health Care Market Place: Carol.com

This "health care market place" portal kicks ass...very well done.

Transparency rules. Secrecy and information hoarding suck.

How to Live to 90

It's not about how many heart imaging studies you can have done.

It is about lifestyle choices, especially after age 70.

Talk about getting the most "bang for your buck".

Health Insurance Brokers and Underwriters: The New Heroes of Healthcare?

I can't fucking believe this excerpt extolling the heroism of brokers and underwriters from a newsletter from the National Association of Health Underwriters, posted at The Health Care Blog:

"...I had a terrific opportunity to speak to 700 health insurance agents and brokers on Tuesday morning, here for the Capitol Conference of the National Association of Health Underwriters, most ably led by CEO Janet Trautwein. These people are entrepreneurs who are on the front lines of saving the private market for health insurance in this country, and they are my heroes..."

More Suppressed Public Health Information

More evidence that the CDC is either overstretched, or receiving instructions to suppress information.

Read the Kaiser Daily Health Policy report on possible suppressed information about cancer risks for Katrina victims.

Bush Budget Reveals $178 Billion Cut in Medicare Spending

From the Kaiser Daily Health Policy Report on Feb 5, 2008:

"....President Bush on Monday released a $3.1 trillion fiscal year 2009 budget request that would reduce Medicare spending by $178 billion over five years, the Baltimore Sun reports (Hay Brown, Baltimore Sun, 2/5). Over 10 years, the budget request would reduce Medicare spending by about $560 billion....In an effort to reduce Medicare spending growth, the budget request 'asks doctors and hospitals to hold the line on what they charge the elderly for medical care' and maintains that 'cuts in Medicare can be painless -- even lowering premiums that seniors pay by capping what doctors and hospitals can charge...'"

Fuck you.

And good luck finding a primary care doc...they get hurt disproportionately.

You know, this is actually the tip of the iceberg in terms of what we can expect to see as a result of diverted funds due to war spending.

Again, fuck you and the one that made you.

More Insight from Maggie Mahar--The FDA

Also referenced in Maggie Mahar's last post on the CDC data suppression is her prior post on "The FDA: What Happens When You Starve the Beast".

This is friggin' brilliant.

And we stand for this bullshit in government?

Suppression of CDC Public Health Data in Great Lakes

Suppression of important public health data...why the fuck would someone want to suppress this?

Check out Maggie Mahar's comments on the suppression of a key CDC report of environmental and health data in the eight Great Lakes states, and tell me what you think.

She mentions:

"....Centers for Disease Control and Prevention (CDC) study of environmental and health data in eight Great Lakes states that was scheduled for publication in July 2007. The report, which pointed to elevated rates of lung, colon, and breast cancer; low birth weight; and infant mortality in several of the geographical areas of concern has not yet been made public....A few days before the report was slated to be released, it was pulled. Meanwhile, at precisely the same time, its lead author, Christopher De Rosa, has been removed from the position he held since 1992. The Center for Public Integrity is asking why."

Is the Bush administration trying to shrink government by cutting so that federal agencies can't do their jobs?

The Failure of "Market-Based" Medicine

The New England Journal of Medicine has an interesting op-ed piece on the failure of market-based medicine.

I agree that healthcare is a mess. 

But it's not the market that's to blame...healthcare is one of the most dysfunctional markets imaginable.  Consumers don't know the cost or the value of the services they get, purchasers are just as clueless, and the glaring fact that someone else is purchasing care on behalf of the consumer leads to huge dysfunction.

I've said before that I'm a supporter of a single-payer approach, but don't try to put me in a box here.  Single-payer, in my mind, would involve blended government and private coverage, but with a single entity paying the bills (Medicare actually does a good job paying it's bills in a timely fashion...reimbursement is another story).  Must haves:

• Must have competition that allows some providers to prosper and others to go out of business, appropriately so.
  
• Must have adequate reimbursement to allow especially primary care providers to stay in business, get rid of debt, and to earn a decent income at the end of the day.  
  
• Must keep primary care and public health in the forefront.
  
• Must have the consumer with some skin in the game (via copayments, etc.)

Universal Coverage and Misnomers

Here's the sort of fucked-up logic in a recent post about Hillary Care on John Washburn's blog that keeps us from getting anywhere with health reform.

Here are my random thoughts:

• What the fuck is "Hillary Care"?  This is the problem with vague terms that entice the less informed to make generalizations that don't have anything to do with key beliefs.  The same is true with the Republican party's strategic use of the term "Socialized Medicine"  If you don't like Hillary Clinton's views on healthcare, then take the time to say specifically what you don't like.  I personally don't like her current approach, but it has nothing to do with providing coverage for all.  It's got to do with the fact that she's tight with the insurance lobby.  It's definitely not the plan she proposed in the past.
• Mandates don't work.  
• Fee-for-service medicine will continue to lead to escalating costs.
• Universal coverage doesn't mean that the solution must automatically be government-run.  And if you accept this and you still have a problem with the concept of healthcare for all (universal coverage), then I wonder why.  Wouldn't society be better if we were all more likely to be healthy?

Coverage and access are two different things.  Medicaid provides coverage, but not access (who's going to be able to provide access when reimbursements don't come anywhere near covering the cost of care?).

I want universal coverage.  I also want universal access.  Universal coverage and access leads to fewer people getting more expensive care in higher acuity settings.  And there's no more money in the pie (or at least, no one is willing to sacrifice for it), so it means that some people will end up making less.

From a business perspective, it makes sense to cut where no additional value is added, and redistribute to where greater value is generated.

This means cutting the ridiculous profits made by the insurance industry (not necessarily killing the industry...I think there are ways to keep the industry happy in a single-payer model).  It also means not letting people do things that don't add value.  Total body imaging is one example...the more sinister examples are the epidural steroid injections, the spine surgeries, the radiologic churning that goes on behind the scenes.  

Yes, the "RAPE" specialties (radiology, anesthesiology, pathology, and emergency medicine) will need to be reigned in...you can't play in the system without having to feel the effects the rest of us have to feel.

It also means taking a stronger stance on end-of-life care.  News flash:  You won't live forever.  Get used to it, and don't squander dollars for that extra six months of miserable quality-of-life.

Don't Doctors Make Too Much Already?

Edwin Leap comments on "How Much Should Doctors Make" in a recent post.

How much should they make?  Just taking the perspective of a primary care physician, it's hard to feel sorry for someone making $130,000 a year, right?

What sucks about this situation is that this income quickly gets spent in paying off school loans, the high costs of malpractice insurance, and all of the other stuff that people deal with.

I've got lots of friends with over $200,000 in student loans.  Some are married to doctors, making the overall educational debt load $400,000.  After school, daycare, mortgage and the other things we all deal with, they are also among the ranks of those living from paycheck-to-paycheck. 

But even then, they seem to do pretty well.  They're far from homeless.  And they've got things that other people don't.

So how much should they make?  How much should anyone make?  Professional athletes, hedge fund managers, recording artists, attorneys?  (Of  course, our culture makes what they have to offer more important than health--can't afford meds but can pay to see a hockey game.)

As Kevin, MD reminds us on his blog, it is true that US physicians make more than physicians in other countries...but so do people in other professions.