Maybe it's a small gesture, or maybe it's merely a way for the pharma companies to cut outlays during a time of retrenching . . . whatever the reason, we will all soon be deprived (freed?) of branded pharma stuff. That's right! No more free pens, sticky pads, penlights, oven mitts, etc. etc. etc.

http://www.nytimes.com/2008/12/31/business/31drug.html?_r=1&hp

NPR on single payer health

Hi All, NPR aired a report last week on the possibility that health care reform will bring a Single Payer system . . . maybe I'm introducing bias, but I think the report ends up echoing what HPfHR has been saying: the political will just isn't there for a Single Payer Plan that would offer universal coverage. Several reasons are enumerated, but chief among them is the idea that a Single Payer plan would be "un-American" somehow. The story also mentions the strong industry that health insurance has become, and the necessity, for reasons good and bad, of including insurance companies in the formulation of the plan. If you're interested, you can lsiten to the story here:

http://www.npr.org/templates/story/story.php?storyId=98374633

After the Elections

The elections are over and now we are ready for the Obama era! What will this mean for healthcare reform? Is the economic crisis going to affect the chances of meaningful reform?

Well, I think that that today's appointment of Tom Daschle to be secretary of health and human services is significant in two ways. First, it's a sign that Obama will pursue real, meaningful, ambitious reform; and second, it shows that he's determined to avoid the mistakes that doomed Hillarycare in the 1990s. Finally, his pick should quiet all the pundit speculation that Obama won't be able to afford the cost or political capital to act quickly and decisively on reform. Daschle wouldn't have taken the job if he didn't think it was a major priority for the new administration.

As one analyst said:

You don't tap the former Senate Majority Leader to run your health care bureaucracy. That's not his skill set. You tap him to get your health care plan through Congress. You tap him because he understands the parliamentary tricks and has a deep knowledge of the ideologies and incentives of the relevant players. You tap him because you understand that health care reform runs through the Senate...
Daschle signals that the Obama administration view health care as a political problem. The key to success is votes. And Daschle is a guy whose last job was lining up votes.

This also is good for EMBRACE, since in his book "Critical" Daschle has proposed a "Healthcare Board" similar to our Board.
Gil

Billy Beane, Newt Gingrich and John Kerry on Healthcare Reform

Billy Beane, Newt Gingrich and John Kerry say in an NY Times Op-Ed piece today that our healthcare system has a lot to learn from modern baseball. They state:

Remarkably, a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures. Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition.

They go on to say:

Similarly, a health care system that is driven by robust comparative clinical evidence will save lives and money. One success story is Cochrane Collaboration, a nonprofit group that evaluates medical research. Cochrane performs systematic, evidence-based reviews of medical literature. In 1992, a Cochrane review found that many women at risk of premature delivery were not getting corticosteroids, which improve the lung function of premature babies.

Even though this Op-Ed seems to be saying what we (HPfHR) are saying, there are several things that bother me.
The first is the statement that:

Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition.

They give no reference for this, but I suspect that if there is literature on it, it is pretty old. As most healthcare professionals know, there has been a significant shift to evidenced based medicine over the last decade that has come from many sources, not just private groups like the Cochrane Collaboration or the Intermountain Healthcare Foundation. In fact most of the recent impetus has been physician driven and is increasingly more readily available for healthcare providers through publications of "Guidelines and Standards" or "Position" documents in major medical journals.
This brings up another thing that bothers me, namely that once again it is the politicians (and now baseball managers!) who are trying to tell the healthcare profession how to practice medicine! I think that we all would love to think that practicing medicine is similar to managing a baseball team. All we have to do is master some empirically derived formulas like "VORP (value over replacement player) or runs created — a number derived from the formula [(hits + walks) x total bases]/(at bats + walks)" and we can cure our patients and bring down costs!
Even though it seems absurd to healthcare professionals that all we need are a set of statistics and a good database system, this will be what is presented to the public by groups like the authors of this piece!
Finally, as to the statement:

Working closely with doctors, the federal government and the private sector should create a new institute for evidence-based medicine. This institute would conduct new studies and systematically review the existing medical literature to help inform our nation’s over-stretched medical providers. The government should also increase Medicare reimbursements and some liability protections for doctors who follow the recommended clinical best practices.

I think that although the "institute" sounds like our "Board" it has several significant problems. First is the involvement of the private sector. Although the private sector should have some representation on our "Board", I suspect that in this "institute", the private sector will hold too much sway and as usually occurs when the public and private sectors compete, costs will go up and efficiency will go down. Secondly this proposal will not work in the current system, since Medicare does not cover the entire population and the institute will have no control over spending.
Billy Newt and John, its a nice thought, but I think that you should let the healthcare professionals take control of this. We promise we won't tell you how to manage a baseball team! (BTW: How did the Oakland A's do this year? Was it 10/14 in the American League?)
Gil

Addendum: In the print addition of the piece, it states that the Intermountain Healthcare Foundation is part of Newt Gingrich's "Center for Health Transformation, a for-profit organization". So much for altruism...

The Presidential Candidates in JAMA

Tomorrow's issue of JAMA has statements from the two presidential candidates about their healthcare plans. In reading the two statements, I noticed two things. The first is that neither plan addresses exactly how it will improve outcomes (except to say that this needs to happen). The other thing is that both clearly feel that healthcare reform is needed. This is good news for our group.
When discussing his plan, McCain says:

We must find better ways to diagnose, manage, and—most importantly—prevent chronic conditions such as cancer, heart disease, high blood pressure, diabetes, and asthma. Many of these chronic conditions are linked to the epidemic of obesity in our country, which is growing at a particularly alarming rate among children. We must find innovative ways to draw on our public health infrastructure, invest in early intervention programs, and find new models to promote healthy habits and begin to roll back these troubling statistics.

He doesn't give any solutions but the very fact that he states that we should "find innovative ways to draw on our public health infrastructure", "invest in early intervention programs" and "find new models to promote healthy habits", is very encouraging that he will be receptive to our model.
Obama's plan does seem to have a bit more detail regarding how it may affect outcomes, but I think that there are some undiscussed assumptions about how well "Requiring disease management programs and integrated preventive care" and "Devoting more of our health care funds to prevention" will really work in the current system. As previously discussed, David Katz points out that even when preventive services are available, people generally do not take advantage of them unless one can build in a good incentive within the system. The HPfHR system's structure will allow for built in incentives (such as receiving Tier 2 coverage if one completes 80% of Tier 1 preventive care goals) without necessarily requiring a larger amount of funds.
So it seems that who ever wins this election, there does appear to be some role for our plan.
Gil

Paul Krugman wins the Nobel Prize!

Today's announcement that Paul Krugman won the Noble Prize in economics, I think, is a very good development for the chances of getting meaningful healthcare reform. Krugman is an outspoken advocate of single payer systems, and for publicly financed systems like Medicare over private insurance. Despite the fact that he won his prize in a completely unrelated field I think that his opinions now will have significantly greater weight than even last week (this seems to be true with many Nobel Prize winners).
Gil

Reading between the lines?

Although there has been a lull in this blog, it isn't that there is nothing going on in healthcare reform.
First, we have sent in our EMBRACE Healthcare Plan proposal to the Annals of Internal Medicine on Wednesday 10/1. This typically takes a few weeks for a response...
We have also heard a lot of mention of healthcare reform during the Presidential debates last week and the Vice-Presidential debates this week. One very interesting thing that Paul Krugman picked up was the source of Sarah Palin's reference to Ronald Regan in her closing remarks:

It was Ronald Reagan who said that freedom is always just one generation away from extinction. We don’t pass it to our children in the bloodstream; we have to fight for it and protect it, and then hand it to them so that they shall do the same, or we’re going to find ourselves spending our sunset years telling our children and our children’s children about a time in America, back in the day, when men and women were free.

It turns out that this was a recording he made for Operation Coffeecup — a campaign organized by the American Medical Association to block the passage of Medicare. Doctors’ wives were supposed to organize coffee klatches for patients, where they would play the Reagan recording, which declared that Medicare would lead us to totalitarianism. (you can hear the full recording here on mp3).
Even though Palin did not use it in conjunction with healthcare reform, it still is interesting (maybe ominous for healthcare reform as a whole) that this is still clearly in the "library" of those who may oppose government supported healthcare. This may be an indication of what we may be facing in promoting our plan.
Gil

A New Name for the HPfHR Healthcare Reform Plan!

Our plan has a new name!

The Expanding Medical and Behavioral Resources with Access to Care for Everyone or:

EMBRACE Health Plan

Gil

The Massachusetts Way

The New York Times had an upbeat editorial today exalting the success of the Massachusetts healthcare program.

The number of uninsured has dropped — Massachusetts now has the lowest rate in the nation — and so have the number of those who turn to costly emergency rooms for routine care. And while the state has had to seek additional sources of revenue — mainly because of the program’s popularity — the gains in the first 21 months suggest that the plan could become a model for universal health coverage for other states or the nation.

What they don't directly state but is inferred is that the majority of the coverage is through Medicaid rather than private insurance. This, as most healthcare professionals understand, is not the same coverage as private insurance or even Medicare, and limits the services and providers that a patient can obtain.
What is not known as of yet and what the editorial also does not mention, is that there are no data on how much this plan has helped the health of the population it is covering and it's cost-effectiveness. Stay tuned...

Connecticut's new health plan has only 24 customers, 2 hospitals

W e previously discussed the Charter Oak health care plan (Connecticut's new initiative for "Universal Coverage"). At the time we had little information on what it was all about. This article appeared today in my local newspaper (The Danbury News-Times) about it. It seems that the plan is having some trouble getting traction...
Other than the high cost to the insurance companies and low reimbursements to providers, I wonder if there wasn't also a problem here of not properly informing the providers and the population about the details of the plan. Does anyone else (in Connecticut) feel under-informed?
Gil

Adddendum:
Today, August 6th, The Danbury News Times had an editorial about the plan.
Some highlights:

This state plan to provide insurance to uninsured adults includes a reimbursement rate so low that it will add to the financial problems that so many hospitals are facing.
"Philosophically, we believe in the importance of health care coverage for everyone," said Danbury Hospital spokesman Andrea Rynn. "Practically, though, Charter Oak relies on hospitals to provide services at rates which will not cover the cost of the care provided. "In recent weeks, Governor Rell has been issuing press release after press release announcing that thousands of Connecticut residents have been calling to inquire about Charter Oak.
The governor didn't mention that only 24 people have actually enrolled. Nor did she mention only two hospitals have agreed to join the program -- St. Mary's in Waterbury and the Hospital of St. Raphael in New Haven. Nor did she mention that physicians have been slow to join.
Nor did she mention that Commissioner Michael Starkowski of the Department of Social Services warned her office against starting Charter Oak before the program was ready.

And it concludes with:

Charter Oak was started with good intentions. But a solid program is needed, not just good intentions.

Gil

I recently had a conversation with Dr. JoAnn Manson about our healthcare plan and she had many insightful comments. One of the concerns that she brought up is how this plan might overload the primary care physician's practice. Now, the increase in volume of patients is something that we had anticipated with our plan and had thought that it would be an advantage for physicians.
As I looked over some of our prior discussions I came across the NY Times article back in April about the Massachusetts experience and then came across a blog entry from Alan Katz from that time. These were his thoughts:

What was apparently overlooked was how the influx of newly insureds into the system is straining the pressure on family doctors and other primary care physicians. As a result there’s waiting lists for some non-emergency treatment that stretches for months in some communities. The Times article recounts one physician in Amherst that is now scheduling physicals for early May — of 2009.
The problem is a serious one. By coming into the system, through subsidized coverage or not, residents of Massachusetts anticipated having access to basic health care services. Yet there’s just not enough primary care physicians to go around.
The United States will need 40 percent more primary care doctors by 2020, according to the American College of Physicians, to accommodate the aging population. It’s hard to see where they’re going to come from. The reasons are many. As the Times story reports, factors include reimbursement rates by Medicaid, and the attraction of a specialist’s practice among them. What’s ironic is that Massachusetts ranks significantly above the average in the per capita number of all doctors and primary care physicians.
Which does one little good if you need a doctor and can’t get one to see you. And none of this means attempts to achieve universal coverage should stop. It just underscores how tough a challenge it will be to make any reform package work.

Be that as it may, it seems to me that this may not be as big a problem as either the NY Times or David Katz think. Part of the reason that patients in the Massachusetts plan cannot get access to primary care physicians is that their newly acquired insurance is Medicaid which pays providers less than 20% of Medicare and even less than private insurance. This effectively bars a significant part of the population from access to private physicians. In other words, there is not enough incentive for the care providers in the Massachusetts plan to really allow for more access. This should not be the case in the HPfHR system (or a single payer system either) since everyone will have the same insurance (at least for Tier 1 services).
That's not to say that I don't believe that when the HPfHR system is first established there won't be an initial influx of newly insured patients flooding the available primary care offices. However, I do think that in the free market (and with some help from enhanced reimbursement from the "Board" and drastic reductions of the overhead associated with dealing with private insurance) primary care will become significantly more attractive. In addition, there is now a significant growth in the ranks of physician assistants and nurse practitioners that is already helping primary care services.
Please let me know your thoughts...
Gil

Doctors Urged Not to Screen Elderly Men for Prostate Cancer

I was reading this today on the NY Times Online edition and it just occurred to me that these are exactly the type of data that will be needed in the HPfHR healthcare system. These new recommendations will probably not only save money but may even reduce morbidity and improve longevity!
What a concept!!
Gil

Doctor and Patient, Now at Odds

Today's NY Times Health section has a disturbing item about what I think we all have been noticing: patients are losing their trust in doctors. Personally, I think that this article only scratches the surface of the issue, especially at the causes:

The reasons for all this frustration are complex. Doctors, facing declining reimbursements and higher costs, have only minutes to spend with each patient. News reports about medical errors and drug industry influence have increased patients’ distrust. And the rise of direct-to-consumer drug advertising and medical Web sites have taught patients to research their own medical issues and made them more skeptical and inquisitive.
“Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified,” said Dr. Robert Lamberts, an internal medicine physician and medical blogger in Augusta, Ga. “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”
Others say the problem also stems from a grueling training system that removes doctors from the world patients live in.

Personally I think the problems are much more to do with the external pressures on physicians (e.g. insurance companies trying to optimize profits by limiting access to testing and services and potential malpractice suits) than their training or even the limited time.
Would love to hear from the group about this...
Gil

Means Testing, for Medicare

The NY Times had a piece on "Means Testing" for Medicare last week that I think is very topical for our group. It brings up an issue that is potentially one of the greatest domestic political liabilities, and one that almost every politician has been avoiding. As the NY Times’ Tyler Cowen points out, none of the healthcare reform proposals by the presidential candidates (nor most of the Congressional candidates either) even identify Medicare solvency as a problem, let alone have a proposal for a fix.
The use of “Means Testing” — cutting back on payments to the relatively wealthy, has been a proposal that has been around for a while, but, as the is pointed out:

The biggest problem with such efforts is measuring and enforcing the rules that establish who receives a specified benefit and who doesn’t. Means testing in Medicaid causes many people to hide income and assets or to transfer assets to family members, so they can look poorer and still get benefits.

And...

Of course, the idea of cutting some government transfers provokes protest in some quarters. One major criticism is that programs for the poor alone will not be well financed because poor people don’t have much political power. Thus, this idea goes, we should try to make transfer programs as comprehensive as possible, so that every voter has a stake in the program and will support more spending.

Although I agree with Mr.Cowen that this Medicare issue needs to be addressed. I completely disagree with his point that:

Advocates of health care reform tend to be long on ideas for expanding care and access, but short on practical solutions for cost control. The argument is often made that single-payer health care systems in Canada or Europe are cheaper than health care in the United States. But Medicare is already a single-payer plan, yet its costs are unsustainable.

This, as we have previously pointed out, mislabels current Medicare as a public, single payer plan. In fact, current Medicare is a complex hybrid that is as much private as it is public. It should never be mistaken as a "single payer" system.
The fact is that a single payer system would take care of this aspect of spending by rationing services as the economic status sees fit. The issue is how to make sure that this rationing is done in a way that allows for the best health of the nation, yet does not restrict access to services to those who would like to pay for them out-of-pocket or through private insurance.
This is where the HPfHR plan has a solution: every one is covered for basic services while allowing for "means testing", preventive services incentives and other methods to improve efficiency while improving the health of the nation.
Gil

Healthcare Professionals for Healthcare Reform

Have you heard of this group, at http://www.pnhp.org/? I wonder if their similar-sounding name to Healthcare Providers for Healthcare Reform implies a similar perspective?
-Ryan

Article in American Journal of Medicine

Interesting commentary in the most recent American Journal of Medicine co-authored by the journal's editor in chief. What's interesting is not the content, none of which is surprising, but the fact that it's the topic-du-jour. Its presence suggests that this is a good time to talk about ideas for Healthcare Reform in the medical literature.
-Ryan

Screening for risk factors or detecting disease.

Here is an interesting report I read on theHeart.org, that is very germane to the subject of prevention and should be of significant interest to our group. It talks about the controversy in the cardiology community that is dividing those in favor of risk-factor screening and prevention on one side from those who advocate early screening for the disease itself.
Although there are many issues here, this ultimately boils down to the controversy between evidenced based information (screening for risk factors) and not yet proven, but compelling diagnostic techniques. I think that the whole argument for me can be summarized by Greenland's statement near the end:

"So I think the only way that this issue is going to get resolved is not by editorials or opinions like mine or Jay Cohn's but by more data, and the data that are needed are clinical trials."

That would be the view of the "Board" in the HPfHR plan as well.
Gil

Preventive Medicine Incentives

One of the major goals of healthcare reform is to make preventive service more available. During a recent telephone conversation with new member David Katz, MD, MPH, we discussed how the HPfHR system could promote preventive services.

Dr. Katz, who has published extensively on preventive services in the medical and lay press, sent me a couple of interesting pieces that discuss the under-utilization of preventive services.

In 2006 he wrote:

Most of us surely agree, in theory, that when it comes to disease, an ounce of prevention is worth a pound of cure. But a new report entitled "Priorities for America’s Health: Capitalizing on Life-Saving, Cost-Effective Services," released last week by the non-profit Partnership for Prevention, suggests that our actions are often at odds with this philosophy.
The report indicates that many vital preventive services are seriously underutilized. The consideration of aspirin to prevent heart disease, for example, is often appropriate in men over age 40, women over age 50, or anyone with heart disease risk factors; yet the topic is only discussed with about 50% of these at-risk individuals. For someone who smokes, quitting is among the best things they can do for their health, and available evidence suggests that physician counseling is a helpful inducement. But only about 35% of smokers receive this professional guidance.
Screening for colon cancer by any of several means has life-saving potential in anyone over age 50, yet is provided to only 35% of this population. The pneumococcal vaccine can prevent one of the most common forms of bacterial pneumonia, and is advisable for all adults age 65 and older; but nearly half of this population is unimmunized. Screening young women for the common sexually transmitted infection, Chlamydia, can prevent further transmission, along with both serious illness and infertility- but 60% of sexually active women under age 25 are unscreened.
The report characterizes not only which preventive services are under utilized, but which, when used, offer the most "bang" for the buck. Beginning with the scrupulous assessments of the utility of preventive services compiled by the United States Preventive Services Task Force, this new report assigns priority scores for 25 preventive services based on their health impact and cost-effectiveness. Each of these is on a scale from 1 (lowest priority) to 5 (highest priority), and the two scores are summed.
Discussion of aspirin use to prevent heart disease, screening and counseling for tobacco use, and childhood immunizations all received a score of 10, making these top priority items. Screening for colon cancer, monitoring blood pressure, flu vaccine, pneumonia vaccine, screening and counseling for alcohol abuse, and vision screening for older adults were close behind with scores of 8. The full list is available at www.prevent.org/ncpp.

In 2007 he added this:

The leading causes of disability and premature death in our society are overwhelmingly preventable. There is consensus among experts that applying what we know now would enable us to prevent 90% of diabetes, 80% of heart disease, and up to 60% of cancer.
What if we dedicated funds to insuring every person in the country (or a given state), but then required them to put that coverage to good use? The United States Preventive Services Task Force (http://www.ahrq.gov/clinic/prevenix.htm) is a non-partisan group of medical experts who conduct exhaustive reviews of the evidence supporting clinical preventive services, such as immunization, cancer screening, and counseling for healthful eating, exercise, and weight control. The reviews of the Task Force illuminate a whole list of services we know not only to promote health and prevent disease, but also to be cost-effective. And other groups have taken this effort further, examining the impact of preventive services relative to one another. Former US Surgeon General Dr. David Satcher lead a group called the National Commission on Prevention Priorities that rank-ordered preventive services on the basis of bang for the buck. Topping their list are aspirin to prevent heart disease, childhood immunization, and counseling for smoking cessation (see http://prevent.org/content/view/49/99/ for the complete list).
Since we have cost-effective means of preventing advanced disease, why not impose on ourselves the responsibility of using them?
How about this: you are guaranteed health insurance only as long as you are substantially in compliance with recommended clinical preventive services? No need to require perfect compliance, but a minimum of, say, 80% of recommended services for your household during any 3-year period, might be reasonable. Published reports indicate that at present, clinical preventive services are substantially under-utilized.
The advantages of people receiving clinical preventive services are considerable. Lives will be saved, cases of advanced disease prevented by virtue of early detection and treatment, and costs reduced. If all clinical preventive services were used as advised, hundreds of thousands of lives could be spared each year, and health care expenditure reduced by $100 billion or more.
A recent report in the NY Times (To Save Later, Employers Offer Free Drugs Now. by Milt Freudenheim. NY Times. 2/21/07) indicates that some companies will provide medications to their employees for free to treat chronic disease. This is advantageous to the employers because well-treated chronic disease is less costly than poorly treated chronic disease. Co-pays reduce an employer’s drug costs, but the evidence is clear and consistent that they drive up total healthcare costs by reducing medication use. So paying the pharmacy bill to ensure that employees actually take drugs as prescribed turns out to be good business, as well as good medicine.

After reading and discussing the HPfHR plan, he suggested that we might be able to encourage preventive services for everyone by (public) financing Tier 2 coverage for those who show more than 80% compliance with their Tier 1 preventive screening services.
I personally think this will be a great addition to the plan and will dove-tail well with our aim to improve the health of the entire population.
Please let me know if you have any other thoughts or comments.
Gil

Medicare Showdown

I think that this over-ride of the Medicare bill is going to be a landmark for healthcare reform. To underscore it's importance, I just noticed that the New England Journal just issued it's web edition and there is a very interesting analysis of the veto over-ride vote that just occurred yesterday (talk about up-to-the-minute!). As with the Krugman Op-Ed and the New York Times editorial (not to mention our own blog post), this NEJM "Perspective" sees this as good for physicians and for Medicare.
I personally also feel that this over-ride may be a turning point in what I believe is an outright war against Medicare and other publicly financed healthcare by the current Federal administration. Until this vote there has been an all-out push to "privatize" all aspects of Medicare, giving every advantage to the private sector so (and I believe this was a deliberate aim) that "public" Medicare will collapse.
Now, I know that Medicare is not perfect, but I think that many of us in the health care delivery end of the issue see that "public" Medicare is more user friendly to both patients and healthcare providers and is more fiscally efficient. In fact, the introduction of these "privatized" plans have only benefited the health insurance industry and made our jobs more difficult (as with the introduction of "pre-approvals" for Medicare patients) and have driven up costs.

Getting back to the NEJM piece; it closes with this;

Although the temporary fix for physician fees will alleviate the immediate concerns of many doctors, the remuneration problem remains unresolved for the longer term. No one is satisfied with the current formula by which Medicare calculates physician fees, but Congress has hesitated to act because of the hefty price tag that would be attached to any change deemed acceptable to both policymakers and physicians. Members of Congress have urged physician groups to develop their own proposals, but because any viable plan is certain to result in both winners and losers, organized medicine, too, has been reluctant to act. So for the time being, annual Band-Aids will continue to be the standard of care for Medicare's physician-payment woes.

So I want to thank Congress for this important vote!... but at the same time it is clear that there is still a great need for a new politically viable system.
Gil

Medicare’s Bias

One of the alternatives to a single payer universal healthcare that has been proposed by Yale's Mark Schlesinger and Jacob Hacker (Hacker has been a key adviser to both the Clinton and Obama campaigns on health policy and also was an adviser in the Massachusetts plan) is an expanded Medicare system. The thinking is that since a single payer system is not politically viable, we need a public/private partnership for healthcare. Their proposal is quite long but well thought out Secret Weapon: The “New” Medicare as a Route to Health Security, Journal of Health Politics, Policy and Law, Vol. 32, No. 2, April 2007) and basically argues that this public/private partnership already exists in modern Medicare. After discussing the merits of an expanded public/private hybrid like Medicare they have the following discussion:

Although competitive hybrids have attributes that can enhance their effectiveness
and political stability, it is important to recognize that this program design also embodies some sources of tension. Precisely because competitive hybrids allow for public and private insurance to coexist, partisans of each will constantly contest the appropriate boundaries between the two and seek to amend the program in ways that favor their preferred form of insurance.
These ongoing political tensions can reinforce some of the administrative challenges inherent in a program that combines public and private insurance. Programs that offer beneficiaries a choice between the two forms of insurance have typically experienced favorable selection by private insurers, who adopt practices that encourage enrollment by relatively healthy beneficiaries and disenrollment among those who are chronically ill (Medicare Payment Advisory Commission [MedPAC] 2000). In the short run, these patterns of selection lead to slightly higher costs
for a hybrid program than for pure public insurance.
The longer-term political implications, however, may be more consequential. Were hybrid programs to adopt policies of fixed contributions (socalled “premium support”
arrangements), existing cost differentials could induce more beneficiaries to select private plans, even if their performance was no better than conventional FFS Medicare (Oberlander 2000). If politicians view the higher costs in the public component as an indication of inefficiency rather than selection, they could lose faith in the public component and try to move beneficiaries and resources to private insurers.

Well, today there was an editorial in the NY Times that we feel confirm these limitations of inherent competition in modern Medicare, and why we believe it may be difficult to simply expand Medicare. Instead of having the private and public system co-exist, we believe that they need to be separated. In our system, private and public coverage exist together (allowing for universal coverage) but separated so that there is no inherent competition.
Gil

Another Chance for Universal Healthcare?

Paul Krugman, an Economics Professor at Princeton and a regular NY Times OP ED columnist, had an interesting OP ED in the Times on Friday. Although it was titled "Kennedy’s Big Day " and started off discussing how Ted Kennedy came out of his convalescence to save Medicare (and doctors), he went on to discuss how this vote was a very good harbinger for the political viability of universal healthcare. A recommended read.
Gil

McCain's Plan

This was on Health08.org today, (a great site run by the Kaiser Family Foundation for a non-partisan look at health care policy):

The New York Times on Wednesday examined a plan by presumptive Republican presidential nominee Sen. John McCain (Ariz.) to expand high-risk health insurance pools as part of his plan to provide greater access to health insurance in an "invigorated individual market." High-risk pools, now based in states, generally help individuals who cannot obtain private coverage because of pre-existing medical conditions or no previous group coverage.According to the National Association of State Comprehensive Health Insurance Plans, such pools have existed for 30 years and cover about 207,000 U.S. residents. "Premiums typically are high, as much as twice the standard rate in some states," but they "are still not nearly enough to pay claims," which has left states to cover about 40% of the cost of the pools, "usually through assessments on insurance premiums that are often passed on to consumers," according to the Times. "Health economists say it could take untold billions to transform the patchwork of programs into a viable federal safety net" as McCain has proposed in his Guaranteed Access Plan, the Times reports. However, the "McCain campaign has made only a rough calculation of how many billions would be needed and has not identified a source for the financing beyond savings from existing programs," and efforts to finance his proposal "will only get more difficult now that McCain has pledged to balance the federal budget by 2013, which already requires a significant reduction in the growth of spending," according to the Times. Cost Douglas Holtz-Eakin, chief domestic policy adviser to McCain, in April estimated McCain's health plan would cost the federal government $7 billion to $10 billion, with five million to seven million uninsured residents targeted for coverage. However, Holtz-Eakin recently said that the cost "could change dramatically" based on the plan's structure. Holtz-Eakin and other McCain health care policy advisers -- such as Thomas Miller, a resident fellow at the American Enterprise Institute, and Stephen Parente, a health economist at the University of Minnesota -- said that the plan likely would cap premiums at twice the standard rates, with subsidies possible for residents with annual incomes less than 400% of the federal poverty level. In addition, financial incentives "would probably be provided to those who effectively manage their diseases," according to the Times. "McCain's proposal would represent a huge increase over the $50 million a year that Congress now appropriates in grants to the state pools," but "several analysts questioned whether even $10 billion would be nearly enough, given that the states now spend about $2 billion to insure 207,000 people," the Times reports. Karen Pollitz, a professor at Georgetown University who has studied high-risk health insurance pools, said, "They are run in ways that protect the profitability of commercial insurers," adding, "They leave the illusion that there's a safety net without there really being much of one"

Gil

Health Care for America Now and Divided we Fail

There have been some interesting developments in the political front that may be of interest to the group. First, I came across an item in the NY Times about a group that is spending $40 million dollars to promote healthcare reform. It's lead spokesperson is Elizabeth Edwards and it was difficult to figure out what plan the group was actually promoting. I finally found the following (but lost the source):

Groups Seek To Promote Health Care as Campaign Issue
Advocacy groups plan to spend more than $60 million to promote and ask presidential and congressional candidates to support proposals to expand health insurance to all U.S. residents, the AP/Houston Chronicle reports. Health Care for America Now, a coalition of labor unions and other organizations that support Democrats, plans to announce a $40 million national ad campaign that calls for access to affordable health care for all residents. The campaign will target important Congressional districts in 45 states and will ask candidates to support proposals that allow U.S. residents to retain their current health insurance, purchase new coverage or enroll in a health plan administered by the government. Richard Kirsch, campaign manager for Health Care for America Now, said, "The whole goal is to create a mandate next year for the president and Congress to enact health care reform that meets our principles."Meanwhile, AARP on behalf of Divided We Fail -- a coalition led by AARP that includes the Business Roundtable, the National Federation of Independent Business and the Service Employees International Union -- plans to spend more than $20 million through Labor Day to promote bipartisan proposals to make health care more affordable. AARP Executive Vice President Nancy LeaMond said, "We felt we needed more than policy ideas, but the political will to actually get something done." Neither of the coalitions plans to endorse a presidential candidate, although a number of the groups in Health Care for America Now have endorsed presumptive Democratic presidential nominee Sen. Barack Obama (Ill.) or have members serving as his advisers (Kuhnhenn, AP/Houston Chronicle, 7/8).

I think it may be important for us to look into both of these initiatives, since neither the Healthcare for America Now or the Divided We Fail coalition seem to have a specific plan. Also, both have stated that they are not supporting one candidate's plan over another. This may be an entree for our group's plan.
Gil

The Senate Stalls on Medicare

If further proof is needed that the system is broken, everyone should read the NY Times editorial today regarding how special interests (i.e. the insurance industry) is holding up what is clearly good healthcare legislation. In case you have trouble with the link above I will copy it:

The Senate Stalls on Medicare- July 5, 2008
Before leaving town for the Fourth of July recess, Senate Republicans thwarted a vote on a sensible Medicare bill that would benefit doctors and patients at the expense of overpaid private health plans.
The House approved the legislation with a vote of 355 to 59. The bill is supported by most doctors, hospitals and pharmacists. But it is vehemently opposed by the insurance industry and its Republican coddlers.
The bill would protect doctors from a 10 percent cut in their reimbursement rates, and it would give them a tiny increase next year. It would also spend more money to enhance preventive services, improve low-income assistance programs and make other modest but worthwhile changes. The bill would largely and sensibly offset the additional costs by reducing payments to the private plans that participate in Medicare.
That has inflamed opposition from the White House and Senate Republicans who seem determined to protect inefficient private plans from the rigors of competing fairly against traditional Medicare coverage. Medicare pays these private plans, known as Medicare Advantage, an average of 13 percent more to provide the same services as the traditional Medicare program.
The new bill would start reducing the payment disparity through some modest adjustments. It would also require the fastest-growing category of private plans — private fee-for-service plans — to organize networks of doctors and hospitals and report measures of quality, just as other private plans do, so that beneficiaries would have guaranteed access to capable medical providers.
The likely result would be slower growth for the private fee-for-service plans, which are the most heavily subsidized and least efficient Medicare plans. That is an outcome to be welcomed, not deplored.
We would prefer eliminating a provision that would postpone a promising new competitive bidding program for durable medical equipment. But even with that weakness, this bill needs to pass so that Congress can start the politically difficult task of wringing unjustified subsidies from the most inefficient private Medicare plans.
In the Senate, every Democrat (except the ailing Edward Kennedy, who was not there) voted to take a final vote on the bill. Nine Republicans went along, leaving the bill only one vote short of forcing a vote and up to eight votes short of a veto-proof majority.
Every American represented by one of the recalcitrant Republican senators should press them to change their votes. Medicare is in deep financial trouble. Voters should demand that their leaders help control spending by reducing clearly unjustified subsidies to private Medicare plans. Let them compete on a level playing field with the government-run Medicare program.

This is why we need an independent Board (as in the HPfHR plan)
that will be able to avoid the whims of Congress.

In the mean time it is important to do as the Times asks and: "Voters should demand that their leaders help control spending by reducing clearly unjustified subsidies to private Medicare plans. Let them compete on a level playing field with the government-run Medicare program. "
GIL

Weighing the Costs Part II

I came across this in the Financial Times. It reviews the pros and cons of the argument that technologies help increase healthcare costs. I think that the argument that it does not really increase healthcare costs, lose out when the example of the CT angiograms are pointed out. As we pointed out previously, the current system is very susseptable to pressures from industry and physicians even when the "system" (i.e. Medicare in the case of CT angios) is trying to do the right thing. Again, I think that the HPfHR model, with a semi-independent Healthcare Board modeled after the Federal Reserve, would be able to withstand these pressures much better and help control cost more effectively.
Gil

New signup

Gil,

Thanks for setting up this blog, it was easy to sign up for, and will leave a nice record of opinions without clogging up the main site. Charles Kochan. (I am also testing to see if it posts my first entry!) ps it worked...........

Connecticut Launches Health Plan For Uninsured

Some have asked about Connecticut's new plan. I have to say that I am not as familiar as I should be with the details, but here is a link to the Hartford Courant on the subject.

On first blush it looks promising, but the devil's in the details. I again need to plead ignorance and say that what I know is what has been written in the media. Although there are many benefits, the Courant article does not discuss specifics about how or even if the private insurance plans are regulated. It is also worth to note that this is not universal coverage and some things we would consider Tier 1 conditions (under the HPfHR plan) such as diabetes will not be covered. Finally, I don't see how costs are to be contained with this plan.

Does anyone have more knowledge of this plan?
Gil

Weighing the Costs of a CT Scan’s Look Inside the Heart

Many have asked me about the front page article in the NY Times last Sunday (June 29th) about CT angios. I have been meaning to comment all week, but this has been a busy time (as the new hospital-academic year started yesterday). It is long and involved, but I think it does cover most of the issues about CTA fairly even-handedly.
From our standpoint , I think this is a very nice example of how the HPfHR model could work well to both control costs and to get evidenced based information that will help the population.
Consider the final section of the article:

Medicare’s Scrutiny
The Centers for Medicare and Medicaid Services had decided to push back.

The agency, which this year will spend more than $800 billion on health care, rarely questions the need to pay for new treatments. But last June, Medicare said it was considering paying for CT heart scans only on the condition that studies be done to show they had value for patients.

Concerned about the overall proliferation of imaging tests, Medicare said it might require a large-scale study to determine the scans’ value.
The plan met with fierce resistance, particularly from a relatively new organization of specialists, the Society of Cardiovascular Computed Tomography. The society has 4,700 physician members and one purpose — to promote CT angiograms.
“For the CT society, this was life or death,” said Dr. Daniel S. Berman, the group’s president-elect. “This decision could essentially put them out of business.”
Galvanized, at a meeting in November in Chicago, the CT specialists vowed to overturn any possible Medicare proposal.
“We didn’t need to be talking about registries and the research,” Dr. Berman said. “We needed to be questioning the wisdom of the Medicare decision itself.”
The next month, Medicare issued the draft of its proposal, saying that it would pay
for the scans only if a large-scale study were conducted. The CT society, along
with other prominent medical groups whose members performed scans, set to work
lobbying the agency and members of Congress.
One group marshaled the evidence the doctors would take to Medicare, arguing that the agency had ignored some studies, including those of the new 64-slice CT scans. Another group visited Congressional offices. Defenders of the technology argued that Medicare had agreed to pay for other tests, like mammograms, without requiring proof that they improved patient care. Breakthrough technologies, they said, need time to prove themselves.
Medicare “set the bar so high, no new technology would be able to survive,” said Dr. Michael Poon, a New York cardiologist who is the CT society’s current president.
Cardiologists met with Representative Carolyn McCarthy, a New York Democrat. In March, she and other members of Congress wrote to Medicare, urging it to reconsider its plan. Eventually, a dozen or so senators and 79 representatives lined up to support the society’s efforts.
And Medicare gave way.
“There are a lot of technologies, services and treatments that have not been unequivocally shown to improve health outcomes in a definitive manner,” Dr. Barry Straube, Medicare’s chief medical officer, explained when announcing that the agency would keep covering the tests.
In other words, the lack of evidence that the CT scans provide measurable medical
benefit would not stop Medicare from paying for them.
Heavy lobbying makes it virtually impossible for the agency to insist on more evidence before agreeing to pay for a new technology, said Dr. James Adamson, chief medical officer for Arkansas Blue Cross and Blue Shield. “Medicare,” he said, “does not make a lot of really hard decisions.”

I, and I say this as a cardiologist, completely agree with CMS's (i.e. Medicare) original decision not to pay for CTAs unless it was part of a study or registry that would determine it's usefulness, cost effectiveness and appropriate use. I was very upset that they caved in to the special interest groups. In the HPfHR model the Board, set up like the Federal Reserve Board, would be much more resistant to this sort of pressure. Yet it would not completely deny access to CT angiograms. Like CMS's original suggestion, the Board might make a CTA a Tier 1 indication if it was part of a appropriateness study. Alternatively, it may decide to fund or underwrite an appropriateness study with industry. But since the Board will be much more insulated from political and special interest pressure, it is more likely this will be implemented.

Gil

BTW: the online version of the NYT article has a great video of CT angiogram.

Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2007

For those who are into statistics, the CDC just released data on the insured and uninsured in 2007. Click here to see the report.

One highlight:
"Almost one-third of children (32.7%) were covered by a public plan, compared with 12.3% of adults 18-64 years."

Also this graph:

Percentage with health insurance, by coverage type and percentage
uninsured at the time of interview for near poor children under 18 years of age: United States, 1997-2007

Notice how private insurance is getting out of the business of insuring children. Now the majority of children are insured by public insurance plans.

Gil

Health Care Reform in Massachusetts PART II

Today's issue of the NEJM has a "Perspective" piece entitled "Health Care Reform in Massachusetts — Expanding Coverage, Escalating Costs" (click the title for the link to the piece).

It is very similar to the NY TImes editorial we posted last week. It seems very upbeat about the added coverage but also points out:

Not all the news is good, however. Perhaps 5% of the state's population — the exact figure is a matter of conjecture and may be higher — is still uninsured, the financial burden of the reforms is increasing, and the challenges of sustaining the subsidized program have been exacerbated by the economic downturn. The features of plans that decrease the cost of premiums also increase out-of-pocket costs for those who obtain care. Although adults reported lower levels of health care needs that remained unmet because of cost in the fall of 2007 than in the previous year, those with low ncomes reported increased difficulty in getting appointments or in finding a doctor or other provider who would see them.

It also says, and I think this is the most important point:

Health care reform in Massachusetts is not a panacea for the many shortcomings of the health care system. It is worth remembering that California, for example, has more people without health insurance (6.7 million) than Massachusetts has residents (6.4 million) and that the financing and delivery of medical care have not changed. Having health insurance is not having health care.

This brings up what is almost always missed when evaluating these healthcare reform plans; does it improve the health of the population? All we know now is that it costs more (even more than projected) and that more people are covered, but what is the benefit?

Gil

Federal Reserve-Like Board

Interesting story in the NY Times last week that I only saw today.

Some of the highlights are:

The Senate had a daylong bipartisan symposium to lay the groundwork for what leaders of both parties predict will be a major push for health care legislation next year.
Senator Max Baucus, a Montana Democrat who is chairman of the the Senate Finance Committee suggested that “some kind of federal health board” could help Congress make technical policy decisions. “How in the world am I supposed to know what the proper reimbursement rate should be for a certain procedure?” he asked. Mr. Bernanke said Congress could establish an independent health care panel like the one used to recommend the closing of military bases. Congress, he said, could approve or reject the panel’s recommendations, but not amend them.

Sound familiar??
Gil

Medicare Improvements for Patients and Providers Act

The House of Representatives passed the "Medicare Improvements for Patients and Providers Act" yesterday. (The roll call can be viewed here:
http://clerk.house.gov/evs/2008/roll443.xml ) This bill blocks the 10% decrease in Medicare reimbursements that is mandated by the "sustainable growth rate" (SGR) formula built into Medicare financing several years ago that aimed to tie physician reimbursement to actual spending and targeted spending.

Physician payments under the SGR formula are tied to the Gross Domestic Product (GDP), which bears no relationship to patients’ health care needs or physician practice costs. Utilization of physician services grows more rapidly than GDP, so using GDP as the standard for utilization growth in the SGR means that the target is always set too low. The formula also does not make adjustments for new Medicare coverage policies. Omitting the costs of such treatments from the SGR targets increases the likelihood of pay cuts. None of the factors in the SGR recognize Medicare spending due to technological advances.


Because the formula stipulates that the adjustmant is reassessed each year and that almost everyone in Congress understands that the formula is flawed, it has meant that each year payment cuts to doctors are proposed at the start of the year until Congress steps in intervenes. Meanwhile the gap grows each year so that the potential cut continues to grow quicly. In fact, the 2006 Medicare Trustees Report predicts cumulative reductions in Medicare physician payment rates of nearly 40% by the year 2015 as a result of the SGR formula.
It is widely felt in Washington that this formula needs to be changed, but it has been estimated that immediate repeal of the SGR could cost as much as $318 billion, according to the Congressional Budget Office. This has led to complete inaction on the part of Congress.

Several proposals have been made by physician groups, but there has been little action. Hopefully, any new reform bill, will do away with SGR!
Gil

Follow Up: I realize that this is only half the story... It turns out that a similar bill in the Senate was blocked by Senate Republicans: Read about it on the AAFP website.
Gil

The Massachusetts Model

On June 16th the NY Times had an editorial entitled "The Massachusetts Model" about how the Massachusetts healthcare plan is progressing. (click link to see the editorial).

I think that the editorial misses the most important objective of healthcare reform: improving the health of the United States population in an efficient and affordable manner. In this respect the Massachusetts plan is unproven or even failing. Like most healthcare reform proposals, the Massachusetts plan aims to achieve universal coverage by expanding either commercial or publicly financed insurance to cover more people. There is little concern about what that coverage actually covers or acknowledgement that different insurance plans offer widely different quality of health care.
This is the reason why the editorial observed that "many of the newly insured reported difficulty finding a primary care physician, and the share of low-income residents using emergency rooms for nonemergency care rose slightly, the opposite of what was supposed to happen." The fact is that Medicaid, the insurance for the poor, is not the same as Medicare or commercial insurance when it comes to paying the provider. For an outpatient consult Medicaid pays less than 20% of the average commercial insurance and 1/3 of Medicare. Since most primary care physicians have staggering levels of overhead and very little "profit margins" in their practice, they cannot afford to take these newly insured patients into their practice. Instead the Medicaid patient continues to use community based clinics or the hospital emergency rooms. This, in turn, provides these patients with lesser or even substandard medical care and still ends up costing more.
Even if the Massachusetts plan is able to reach its goal of universal coverage, it is unlikely that they will be able to show better outcomes for its enrollees. The most effective solutions for health care reform are those that will be able to cover the entire population equally for the most important forms of healthcare; namely, life saving and life extending conditions as well as preventive care. This will require a healthcare system that is predicated on affordable evidenced-based proven therapies available to everyone on an equal basis.
Gil

Common Good

Mark Thompson, the executive director of the Fairfield County Medical Association wrote:

"Any proposal for reforming our health care system (and I like the idea of
tiering of health care benefits based on level of necessity, a federal health board orchestrating the system, a single clearing house for claims, common plan designs to simplify comparison shopping, etc.) must also have corresponding reforms to our legal system for adjudicating medical liability claims.
Special health courts and an administrative compensation system as advocated by the group called Common Good seems like a reasonable approach for injecting some predictability into an otherwise chaotic process that's based more on the whims of the jury and theatrics of the lawyers.
Billions of health care dollars are wasted each year practicing defensive medicine and defending against frivolous cases."

Their website (http://commongood.org/index.html) has details on this plan. The brochure is a must read (http://commongood.org/brochure-hcare.html) . Navigating the website, I have not been able to find more detailed descriptions, but I think that the concept sounds good.

Certainly with a central Board overseeing the "Federal" evidenced based funding and delivery of health care, it will be somewhat easier to adopt "Health Courts" as more local adjudicators.

Gil

The HPfHR proposal

The following is an updated version of the HPfHR 3 tiered plan for reforming healthcare. The plan is based on the tenet that the entire population should be covered for life sustaining and health promoting “basic” healthcare, with the added belief that there should be the ability to obtain higher levels of coverage for those desiring it. In addition, the plan is designed to make healthcare delivery more effective and efficient. The group has strived to use mostly existing and tested concepts, agencies and plans that will make the transition to the new system less difficult.


The HPfHR 3-Tier System
The base level (Tier 1) of the new healthcare system would cover the entire population- “from cradle to grave”. Based on evidenced based data, it would include all medical, surgical and psychiatric issues considered life saving, life sustaining and/or preventative. Examples would include outpatient services for conditions such as hypertension, diabetes, coronary disease, cancer, severe and persistent mental disorders, preventive medicine and pregnancy care. It will also cover most non-elective inpatient care and some elective inpatient admissions for therapies shown to be life saving, life sustaining and/or preventative.
Tier 2 would cover all medical, surgical and psychiatric conditions considered to help with quality of life. These would include general medical conditions such as low back pain, knee replacement or other orthopedic interventions, and milder emotional conditions that do not impair functioning (e.g. adjustment reactions).
Tier 3 would apply to all medical and surgical issues considered as luxury or cosmetic. These would include items such as “face lifts”, Lasik eye surgery and Botox injections.

Oversight

The Tier system would be overseen by a panel of physicians and other healthcare professionals, public health experts and economists specialized in health care, known as “The Board”. This Board’s mission will be to promote the health of the United States in a socially responsible and economically sound way.
Similar to a recently proposed “Federal Health Board”[i], the Board would be a quasi-governmental organization resembling the Federal Reserve, which should make it less beholden to political pressures. It will have oversight of CMS (Centers for Medicare & Medicaid Services), the FDA (Food and Drug Administration) and the NIH (National Institutes of Health). Using the already established DRG (Diagnostic Related Group), APC (Ambulatory Payment Classification) and ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes, the Board would decide which diagnoses and which services are covered by Tier 1, 2 or 3. For each coverage item, the Board would consider the medical importance (using evidence-based data including practice guidelines developed by expert medical panels, Cochrane Database reviews and other sources), the public health and economic impact. The Board would also be able to direct the FDA and NIH to commission Tier specific research to help it make better Tier determinations (see below).

Although it’s decisions about Tier allocation will be final, the Board will have hearings similar to those of the Federal Reserve for general appeals (not for individual cases).
Health Information Technology
To address the excessive overhead involved in claim submission by providers and institutions due to myriad payer-specific forms, a universal reimbursement form (URF) would be created by the Board and would include all necessary data required to route payment requests for services rendered to the appropriate tier provider. Ideally, this would be implemented electronically using a web based tool distributed to hospitals and physician offices either through private vendors or a government/private industry coalition.

The Board will also be responsible for overseeing the development of a uniform standard for Health Information Technology (HIT) including electronic medical records (EMRs) and test reporting. This uniform standard will guarantee that as HIT is developed through private and public initiatives, there will be complete compatibility.

Funding

Tier 1: Funds for Tier 1 would be provided through a government subsidized account similar to Medicare. The method of raising this revenue can be similar to the present funding of Medicare (e.g. FICA), other payroll taxes (indexed to salary), a tax on businesses based on the number of employees (and their wages) or a combination of these. Medicaid will be eliminated, and therefore will not require funding. Since the number of items covered by Tier 1 in this new system would be substantially less than what Medicare and Medicaid cover now, there would be funds to redistribute and achieve universal Tier 1 coverage. We believe that this will be a “revenue neutral” redistribution. Theoretically funding also could be achieved through a commercial entity as long as it is regulated to follow the profit margins/overhead now achieved by Medicare.

Tier 2: Private insurance carriers would administer Tier 2 services. The private insurance carriers would be allowed to offer a limited number of plans that would be developed by the Board (similar to the Medigap Plans A to L now stipulated by CMS)[ii]. Although each insurance carrier does not have to offer all the plans, the plans that are offered must cover all the services stipulated by the Board. This in turn assures that consumers (either employers or individuals) can compare the price of the plans and can be confident of their coverage.

These plans can be broad (covering most Tier 2 services) or can be customized for specific groups: a geriatric plan that covers extended care facilities but not fertility care, or a heavy laborer plan that includes chiropractic therapy. The price of this private coverage can either be regulated (variant 1), funded with tax incentives or health savings accounts (variant 2) or left to the “free market” (variant 3).

Tier 3: Tier 3 would not be covered under this system (as is true in the current system) and all bills would go to the patient.

Billing

All billing for services (whether in the hospital or office) would be submitted to one “Clearing House” using the URF previously described. Based on the patient’s diagnoses and the services rendered, the Clearing House, through it’s computer based program, would pay the provider directly for Tier 1 items. Those judged to be Tier 2 items would trigger a search for private insurance coverage and if found would be charged to the private carrier. Those without insurance would be billed directly to the patient.

If the service is determined to be Tier 3, the patient is billed.


Therapeutics and Pharmaceuticals

The Board will be better able to accomplish its overall mission (to improve the health of the country and reduce costs) if it has oversight of the NIH and FDA. This will allow the Board to direct research focused on pharmaceutical and therapeutic issues that it needs to achieve its mission. This may be done with a combination of public/private funding depending on Tier. For Drug development, one possibility is to have public funds go to develop Tier 1 therapies (and then Tier 1 owns the drug) while private funds will finance Tier 2 drugs (with the pharmaceutical company owning part or all the rights to the drug when approved).
Drugs will have similar Tier assignments as medical coverage: Tier 1 will be formulations and therapies that have been shown to treat or prevent life threatening illnesses. Tier 2 will apply to those drugs and therapies that increase the quality of life and Tier 3 will be for “luxury” items. Tier 1 medications will be owned by the Board and distributed either for free or at an affordable rate (can be linked to income). Tier 2 drugs will be owned by the pharmaceutical companies, but these firms will not be allowed to advertise prescription drugs to the public. Like Tier 2 medical coverage, these medications will either be covered by one of the Tier 2 insurance plans or will be paid “out-of-pocket”. Tier 3 will all be out-of-pocket and can be advertised.
[i] Tom Daschle, Scott S. Greenberger, Jeanne M. Lambrew, Critical. What we can do about the health-care crisis (New York: St. Martin’s Press 2008), pp.169-171
[ii] CENTERS FOR MEDICARE & MEDICAID SERVICES , 2008 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare http://www.medicare.gov/publications/pubs/pdf/02110.pdf (Accessed April 28, 2008).

Welcome

I am launching this blog today (Friday the 13th of June, 2008) to begin a discussion on how to change the current healthcare system from the viewpoint of the healthcare provider and the patient. Please visit http://www.healthcare-reform.org/ to view our proposed 3 tiered plan.

Over the next few weeks we will post some important articles and links dealing with healthcare reform. Please feel free to joint the discussion on this blog or join our group (membership@healthcare-reform.org).
Gil