healthsignals new york

I still doubt it

For whatever it's worth, as a follow up to a rather jaundiced view of the "emerging consensus" on health care, I tried one of our favorite tests.

Using Google News, I searched on "Uninsured health."

Got 2,860 hits. Six months ago, we got 1,900. What did you get?

More web chatter on health insurance

There's more talk among the bloggers on health insurance and universal coverage

Ezra Klein has posts here on health savings accounts (he found one he liked) here in defense of socialized medicine and a post on his side of a back and forth with Cato's Tim Lee at Bit Bucket on coverage. Here's one of the posts on Lee's side.

Lee was churning it out ... Here for example is his side of a debate with Matthew Yglesias on mandatory private insurance. And here's Yglesias's side.

And here's Lee on HSA's and here's another on the same topic. And another.

And Yglesias also posted and responded to Leif Wellington Haase, the author of the universal health care plan he criticized.

I've barely time to read them all, much less weigh in and it's going to be especially slow posting this coming week.

Strange bedfellows on health care?

The Times is still covering Washington talk of "an emerging consensus" on health care. Here's the latest, this time from Robert Pear (here's a backup link).

This effort holds as much promise as any I've participated in over the last decade, probably more," said Kate Sullivan Hare, the executive director of health care policy at the United States Chamber of Commerce

Well, I've got mixed feelings about this one. Upside? A mixed group is talking. Downside? It's all Washington groupies. I've been part of such "strange bedfellows" efforts at the state level and even brought a couple of them together myself. From time-to-time, they're effective and those are very gratifying, but they're mostly not. Personal good will and scholarly interest are not enough. And think tanks are definitely not enough. There's got to be some real grassroots juice.

Here's what such groups can do:

• Provide cover for elected officials who want to do something anyway. But that certainly doesn't apply in today's Washington
• Push elected officials to act. Works sometimes, but very, very rarely on an issue of this scope.
• Coordinate messages from disparate grassroots groups. Who knows whether that's going on here and how much heft they have.
  

So it's continued discussions are a good sign, but don't get your hopes up.

Moreover, this group is already deep into wonk-think:

People are uninsured for different reasons," said Dr. Mary E. Frank, the president of the American Academy of Family Physicians and a participant in the talks. "No one solution will work for everyone. We need different solutions for different groups of the uninsured."

With all due respect to Dr. Frank and AAFP, which has been quite good on coverage issues, one point does not follow the other. "People are uninsured for different reasons" is true, but only narrowly - within the current mixed bag system. As soon as you begin thinking like this, you've given up universality. And as soon as you begin talking like this, you've given up political ground to those who don't really care about the issue, but don't want to get burned politically and to those who are actively resistant.

Some conservatives may truthfully embrace expanded coverage but due to ideological constraints, confine themselves to limited proposals. Some may use false sympathetic rhetoric to protect themselves politically, but then say that if we fail to reach universality, well that's just unfortunate. The more important principle to them is that there is no legitimate role for government (George Bush, for example, in responding to an uninsured woman during his first Presidential campaign, saying he "wished he could wave a magic wand" but ...).

This is not the first Times article on these discussions. Steve Lohr wrote in the Times business section on December 6 of last year, "The Disparate Consensus on Health Care for All". I didn't buy the headline then which is why I didn't bother posting on it.

Lohr cited Peggy O'Kane, head of NCQA ("no one wants to touch it"), Dr. William McGuire, CEO of UnitedHealth Group (who supports mandatory insurance and focuses more on what's covered), and Dr. David Himmelstein of the Harvard Medical School, who's a single-payer advocate.

Maybe there's a consensus among "experts" (think of the folks who show up at an APHA meeting) on the need for universal coverage of some form, but there's certainly none among elected officials or the public.

The article didn't even keep up with the then current news:

The Bush administration and conservatives say the way to cover the uninsured is to make insurance affordable mainly through tax subsidies (emphasis added) for companies, especially small businesses, and encouraging them to offer high-deductible insurance plans that cost employers less. Individuals, under this approach, are encouraged to set up tax-free health savings accounts to pay for more of their own care.

Hard to make insurance affordable through tax subsidies when you're proposing eliminating tax subsidies.

The inconsistency aside, what was meant by "tax subsidies"? The answer is crucial. Is it the Bush Administration's ever ready solution to everything, tax cuts? Or were they actually talking about something akin to the Earned Income Tax Credit, a refundable credit? Such credits generate, through the tax system, a net transfer to the lowest income people, but they have increasingly been the butt of conservative criticism? (Check here and here.)

Lohr's article goes on:

Newt Gingrich, the former House speaker who is the founder of the Center for Health Transformation, a policy research group, recommends a package of federal and state tax incentives and programs that go beyond the Bush administration proposals. He estimates that his approach could result in more than 95 percent of the population's being insured. "We could radically change the current discussion about the uninsured," he said.

Well maybe. But there there are legitimate questions about the robustness of any approach that leaves a door open to seepage. Yes, there might be an increase in the number of people covered, but absent a structure that's designed to sweep everyone in (or if it's a big deal to you, every citizen), it's not only not going to happen, it's not going to get close.

But assume for the moment that Gingrich is correct. Getting to 95 percent would be a striking change. But why is it that so many Republican leaders are satisfied with that? What's wrong with 100 percent?

We can all speculate and much of our speculation would be about motivation which is always a iffy venture.

And don't get me started tonight on the single-payer proposals.

Now if the Christian Coalition was part of this "emerging consensus," that would get my attention. That would truly make for strange bedfellows.

 

Other people's money

In my too long queue of posts waiting to be finished were several that linked to Paul Krugman's column in the New York Times. As part of my effort to clean up unfinished work, but also to get the those with Krugman links up before the Times starts charging for access to their op-ed columns, here's one of them.

In, Passing the Buck Paul Krugman referenced some World Health Organization (WHO) data, and pointed to the efforts of private insurers "trying to get someone else to pay the bills," as the explanation for why we spend so much more on health care than other developed countries without appearing to get much benefit for it.

According to the World Health Organization, in the United States administrative expenses eat up about 15 percent of the money paid in premiums to private health insurance companies, but only 4 percent of the budgets of public insurance programs, which consist mainly of Medicare and Medicaid. The numbers for both public and private insurance are similar in other countries - but because we rely much more heavily than anyone else on private insurance, our total administrative costs are much higher.

Well trust me, the public sector may pay a smaller percentage, but it's not as if it isn't also trying to shift the costs elsewhere. You can read Paul Castellani's book, From Snake Pits to Cash Cows for example or talk to any number of people who've made their careers in state government by figuring out how to Medicaid (as a verb) new services in order to draw Federal funds. (Using Medicaid as a verb is insider talk and it refers to changing, sometimes distorting, program configurations primarily to draw funds.) Or talk to home care managers who are pressured by Medicaid agencies to bill Medicare first, sometimes pushing them close to the point of being charged with Medicare fraud. It's all the same system behavior, an inevitable by-product of having multiple payers.

Nevertheless, Krugman's larger point is correct.

Palm Pilot and the challenges of interoperability

Take a look here at John Faughn's Slashdot comment on the future of Palm as an indicator of the "complexity of integration" in health care. (The comment is repeated here at Faughn's own site.)

I've used a Palm Pilot for a number of years now and I use the Palm Desktop on my PC to synchronize with the handheld. It's pretty straightforward while working in isolation.

However ...

When I last worked for another company, they used Microsoft Outlook and Exchange and were pretty insistent that certain staff people publish their schedules openly so that others could know where they were and where there were schedule openings. But they did not buy PDAs for staff so we chose and purchased our own.

Synchronizing the Palm with Outlook was a horror. The process lost data or it duplicated data (imagine having to delete, one-by-one, 2,000 duplicate contacts on both the PC and the handheld). Ultimately, I printed my schedule and made copies. Pretty stupid for an IT company, right?

Now this process is dealing with relatively simple data: a contact list, calendar, task list, and notes and relatively simple processes, synchronize one device with another. Right?

Now let's step up to medical records embedded in multiple process organizations and processes. Ohhhh. Maybe that's why things are so slow. Vastly more complex data embedded in multiple vastly more complex processes.

So the next time I'm frustrated with the pace of integration, I'll open up my Palm.

Another form of "clawback"?

A colleague with great expertise in income support policies and programs told me yesterday that he had just learned that the US Department of Agriculture, which administers the Food Stamps program, will be counting the Medicare Part D pharmaceutical benefit as income to low income Food Stamps beneficiaries. More "income" means lower benefits.

He's researching it and I will too, but he's usually got this stuff nailed.

What's it mean? The more Medicare pays for drugs, the less Food Stamps you get. Worse, if true, the Food Stamp benefit will change monthly based on what Medicare spent for drugs in a prior period. Mind you, because of the way Food Stamps work, there may still be a positive net benefit. But this will be an administrative morass as well as making the lives of beneficiaries more uncertain.

The Administration giveth and the Administration taketh away.

Well, since everyone else is talking about it

Well, we've had our fun with Medicaid and Viagra. But I just know that if I don't repeat what everyone else is pointing to today that everybody will think I'm just out of it, namely that New York's State Comptroller, Alan Hevesi, has discovered that not only is Medicaid paying for Viagra and similar drugs, it's doing so for sexual offenders. There's been lots of news coverage, of course. As of this writing, there were already a few hundred links on Google News including the NY Daily News Free Viagra for Pervs, Newsday's Feds try to deny Viagra to sex offenders on Medicaid, and even the UK's Times, US government gives free Viagra to paedophiles.

Great catch, Alan. For you non-New Yorkers, he's a smart guy who, despite his properly serious public demeanor, is probably privately shaking his head on this one.

Couple of observations:

• Hevesi rather deftly tossed this issue to the Feds and they're the ones "scrambling" in most of the news coverage. I wouldn't want to be in Leavitt's office today.
• Hevesi's auditors found the problem by matching the Medicaid claims data they have with the listings of Level 3 Sex Offenders listed on the Division of Criminal Justice Services (DCJS) Sex Offender Registry. Linking Medicaid data with data from other sources is one of the things that's explicitly forbidden by the Department of Health for others who wish to use the Medicaid data.
• Apart from the taxpayer's money that's being used to pay for the drugs, how aware are the physicians who are prescribing of the backgrounds of these patients? If the physicians don't know, should they be and how might they be made aware? Physicians' first ethical obligations are to their patients. How does or should that influence the decision to prescribe in these cases? Are there any instances in which there is a medical justification for the prescription despite or even because of the patient's legal history?
• You just know that somebody is going to take this the next step and suggest that felons, or at least these felons should not be entitled to Medicaid. Let's not go there right now. Just deal with the issue at hand.

Now back to our regularly scheduled programming.

These stumbles are to be expected, but ...

Buried in this HIStalk post from CIO Ed was the following:

One provocative development in the "battle" between the Continuity of Care Record (ASTM) and EHR (HL7). Some will say that the CCR can be a stepping stone towards an EHR and there are many strengths to the CCR concept. Others say that the CCR will be divisive and distract full adoption of the EHR. Lots of pros and cons that must be seriously considered.

Competing standards organizations ... competing standards. Check this from a year ago. (I've not been immersed in this process and don't yet know what the inner dynamics or the latest stories are.)

As I understand the CCR, it's not supposed to be the entire record itself, but the essential elements that can be passed across organizational boundaries. (I'm less familiar with HL7.) Say for example, a patient was in a hospital ICU last year. Whether atoms or bits, the volume of hospital data on that patient is immense. Now say the patient is seeing a physician for a routine visit. Does the physician need all of that hospital data? Not likely. They need to know the patient was hospitalized, was in the ICU, certain essential elements and how to get more data if necessary. So the CCR concept makes sense for interoperability, moving patient-centric information across space, time, and organizational boundaries.

ASTM has been voting on the latest version of the CCR standard. There was enough dissent that they're going to continue thrashing out the issues rather than count it as an accepted standard.

Yes, these stumbles are frustrating. But they're part of a long, hard, often tedious process that is essential to make progress.

TEPR and other IT stuff

Each year, the Medical Records Institute sponsors the conference "Toward an Electronic Medical Record" (TEPR). I didn't go this year, but a couple others did.

Here, here, here and here are Matthew Holt's comments.

Ned Versel posts several news items and links here.

E-Health-Insider covered the mock trial of EHRs. Mock trial? Seems a bit desperate doesn't it?

David Brailer was supposed to be there, but canceled. Another bad sign for the conference? He's been at damn near every other related event.

HIStalk has a couple of posts on the conference starting here and here.

HIStalk also quotes an anonymous conference-goer saying along with other criticisms, 

... it's a dying conference, remnants of medical records staff trying to make way in EMR world.

The same post at HIStalk zings HIMSS Analytics too.

HIMSS Analytics releases its annual report. You can buy it for $60 or, if you want to save the money, here's the first item listed in the summary: "Underinvestment in information technology continues." Franco still dead, full story at 11.

For those of you too young to remember the early SNL bit, it translates as "duh." Funny.

Elyse has a slightly longer and less wry summary here, but the essence is the same.

Medicaid cap followup 3

The Medicaid cap is not just a financial change, it portends an operational change. This is personally symbolized by the return to government service of Brian Wing.

Brian's the former Commissioner of Social Services and then after re-organization, OTDA. He left a while back to work in the private sector.

Brian's returned and has joined the Health Department, specifically the Office of Medicaid Management and his charge is to figure out how to move the Medicaid functions currently administered by localities to the State. This is the administrative/operational change that needs to accompany the cap on local financial responsibility.

That's a change long overdue. The first policy paper I ever had published, Barriers to Medicaid Reform, emphasized the dispersion of policy and administrative responsibility for Medicaid between different State agencies and different levels of government. That was in 1976. Well, we're finally making progress.

Brian's job will not be fun and it's won't be headlines sexy. But it will be important. Best wishes and welcome back.