Tuesday, July 28, 2009

HR 3200 and The Exchange: A Government Regulatory Mechanism

The Health Insurance Exchange is a major part of the HR 3200 Bill. Simply stated, the Exchange is a co-op wherein a group is established and then negotiates some "good" deals for its members. The AMA and many other professional groups have exchange type functions and they work reasonably well.

The problem with health care today is the residual of company provided plans and many being gold plated and not taxed. This is particularly true of Union members and Government employees whose benefits have exploded over the years and the benefits are compounded by the lack of taxation. The benefits then extend to their early retirement resulting is ever so much more explosive costs. Just look at GM and the State of California!

Along comes HR 3200 and it says that the Government and ONLY the Government can do exchanges. It takes it one step further and creates a public plan that will drive out all other players, level playing field notwithstanding. We will examine this in detail.

Just to put our opinions on the table. We believe in the following:

1. Universal coverage, no leakage, no scamming the system

2. Individual and not corporate or employer coverage

3. Taxation of coverage on an before-tax basis

4. Catastrophic coverage mandate for all

5. Out of pocket expenses expected unless you want to pay for the added benefit, and

6. Exchanges are an ideal platform to accomplish this. By exchanges we mean private and group based exchanges, and not a public Federal Government managed exchange.

We detailed this in our most recent book on Health Care Policy.

Now Exchanges for the purpose of purchasing health insurance may be a structure whose time is coming. In the recent NEJM article by Frank and Zeckhauser they state:

"Exchanges focus on the purchase of insurance for individuals, households, and groups of small employers — all of which will be more likely to obtain coverage if it is made more affordable or more available, and certainly if it is made mandatory. Exchanges mimic some functions that are performed by large employers as purchasers, including assembling, organizing, and disseminating information about competing health plans; enacting policies that promote risk pooling; specifying benefit packages; negotiating premiums; limiting the number and types of plans that may be marketed; and structuring the enrollment and plan selection process. They thus seek to extend to all consumers the benefits of having a large employer purchase one's insurance."

They continue as follows:

"Should exchanges play a similarly active role in structuring and managing the health insurance market, so as to guide people to appropriate plans, enhance competition, and thereby improve quality and reduce price? A few decades ago, the conventional wisdom in economics was that individuals could make effective choices in markets, even when the options were numerous and complex. Extensive research in behavioral economics calls this belief into question. In many circumstances, particularly when uncertainties and high stakes are involved, consumers have trouble making good decisions. The purchase of health insurance presents just such challenges. Hence the potential benefits of exchanges.

"Consumers facing complex, uncertain, and consequential choices may also rely on simple rules of thumb. An analysis of Medicare recipients choosing among PDPs suggests that they used such rules to their detriment5 — for example, by overweighting premium outlays and slighting the total expected out-of-pocket costs. As a result, many chose a plan that was expected to be more costly and offered no advantages in terms of features or quality. "

These experiences suggest that exchanges should be structured to foster effective consumer choices, and thereby efficient outcomes, by providing consumer-friendly information about the coverage, cost, and quality of different plans. Ironically, one way to enhance the prospect of informed choices is to limit the number of options. Plans then compete on price, quality, or both in order to be included. Requiring plans to offer identical features would promote competition and facilitate decisions but limit choice. The trade-off between these objectives should be carefully weighed by officials legislating, designing, and operating exchanges."

HR 3200 is filled with elements of creating exchanges. Unlike many of the other exchange ideas floating about the HR 3200 is a Government controlled Exchange including a public plan. We feel that it is worth the while to look at this legislation is some detail. By deconstructing the law as written one gets to see what is in the mind of those who wrote it. They clearly despise private enterprise and demand ultimate Government control. We will see this play out as we go through the key sections on the Exchange. Let us start the process.

In HR 3200 the details about an exchange are in Title II and the three following subtitles. These are shown below.


Subtitle A—Health Insurance Exchange

Subtitle B—Public Health Insurance Option

Subtitle C—Individual Affordability Credits

In subtitle A we have the details of the exchange. The full set of elements are shown below.

Subtitle A—Health Insurance Exchange

Sec. 201. Establishment of Health Insurance Exchange; outline of duties; definitions.

Sec. 202. Exchange-eligible individuals and employers.

Sec. 203. Benefits package levels.

Sec. 204. Contracts for the offering of Exchange-participating health benefits plans.

Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plan.

Sec. 206. Other functions.

Sec. 207. Health Insurance Exchange Trust Fund.

Sec. 208. Optional operation of State-based health insurance exchanges.

Subtitle B—Public Health Insurance Option

Sec. 221. Establishment and administration of a public health insurance option

as an Exchange-qualified health benefits plan.

Sec. 222. Premiums and financing.

Sec. 223. Payment rates for items and services.

Sec. 224. Modernized payment initiatives and delivery system reform.

Sec. 225. Provider participation.

Sec. 226. Application of fraud and abuse provisions.

Subtitle C—Individual Affordability Credits

Sec. 241. Availability through Health Insurance Exchange.

Sec. 242. Affordable credit eligible individual.

Sec. 243. Affordable premium credit.

Sec. 244. Affordability cost-sharing credit.

Sec. 245. Income determinations.

Sec. 246. No Federal payment for undocumented aliens.

Now let us detail several of the key parts of this Title. First, the establishment of the Exchange as follows:

(a) ESTABLISHMENT.—There is established within the Health Choices Administration and under the direction of the Commissioner a Health Insurance Exchange in order to facilitate access of individuals and employers, through a transparent process, to a variety of choices of affordable, quality health insurance coverage, including a public health insurance option.

Thus this statement does the following:

1. Establishes a Health Choice Administration, a new Government Agency

2. Creates a Commissioner

3. Facilitates an exchange for affordable and quality health insurance

4. Creates a public option

The Commissioner now has the authority as stated:

(b) OUTLINE OF DUTIES OF COMMISSIONER.—In accordance with this subtitle and in coordination with appropriate Federal and State officials as provided under section 143(b), the Commissioner shall—

(1) under section 204 establish standards for, accept bids from, and negotiate and enter into contracts with, QHBP offering entities for the offering of health benefits

(2) ….. facilitate outreach and enrollment in such plans of Exchange-eligible individuals and employers ….

(3) conduct such activities related to the Health Insurance Exchange as required, including establishment of a risk …..

Now the individuals are granted access as follows:

(a) ACCESS TO COVERAGE.—In accordance with this section, all individuals are eligible to obtain coverage through enrollment in an Exchange

(b) DEFINITIONS.—In this division:

(1) EXCHANGE-ELIGIBLE INDIVIDUAL.—The term ''Exchange-eligible individual'' means an individual who is eligible …

(2) ACCEPTABLE COVERAGE.—For purposes of this division, the term ''acceptable coverage'' means any of the following:

(A) QUALIFIED HEALTH BENEFITS PLAN COVERAGE.—Coverage under a qualified health benefits plan.


(C) MEDICARE.—Coverage under part A of title XVIII of the Social Security Act.

(D) MEDICAID.—Coverage for medical assistance under title XIX of the Social Security Act, …

Thus you have to must be in the exchange unless you are poor, old, or grandfathered. Thus as written it will eventually drive all out of the grandfathered plans into the Exchange Plans. The benefits are as described below:


(a) IN GENERAL.—The Commissioner shall specify the benefits to be made available under Exchange-participating health benefits plans during each plan year, consistent with subtitle C of title I and this section.

(b) LIMITATION ON HEALTH BENEFITS PLANS OFFERED BY OFFERING ENTITIES.—The Commissioner may not enter into a contract with a QHBP offering entity under section 204(c) for the offering of an Exchange-participating health benefits plan in a service area unless the following requirements are met:

(1) REQUIRED OFFERING OF BASIC PLAN.—The entity offers only one basic plan for such service area.

(2) OPTIONAL OFFERING OF ENHANCED PLAN.—If and only if the entity offers a basic plan 0 for such service area, the entity may offer one enhanced plan for such area.

(3) OPTIONAL OFFERING OF PREMIUM PLAN.— If and only if the entity offers an enhanced plan for such service area, the entity may offer one premium plan for such area.

(4) OPTIONAL OFFERING OF PREMIUM-PLUS PLANS.—If and only if the entity offers a premium plan for such service area, the entity may offer one or more premium-plus plans for such area. All such plans may be offered under a single contract with the Commissioner.

Now the law starts to specify the minimum and maximum plan offerings in statutory law. This is very dangerous because as all plan administrators well know as medicine changes we want the plans to adapt. But by making this statutory law we make it near impossible to ever change it. These four divisions further make such changes near impossible. Now they detail the options:


(1) IN GENERAL.—The Commissioner shall establish the following standards consistent with this subsection and title I:

(A) BASIC, ENHANCED, AND PREMIUM PLANS.—Standards for levels of Exchange participating health benefits plans: basic, enhanced, and premium (in this division referred to as a ''basic plan'', ''enhanced plan'', and ''premium plan'', respectively).

(B) PREMIUM-PLUS PLAN BENEFITS.— Standards for additional benefits that may be offered, consistent with this subsection and sub title C of title I, under a premium plan (such a plan with additional benefits referred to in this division as a ''premium-plus plan'').


(A) IN GENERAL.—A basic plan shall offer the essential benefits package required under title I for a qualified health benefits plan.


(3) ENHANCED PLAN.—A enhanced plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided...

(4) PREMIUM PLAN.—A premium plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided ...

(5) PREMIUM-PLUS PLAN.—A premium-plus plan is a premium plan that also provides additional benefits, such as adult oral health and vision care, approved by the Commissioner. The portion of the premium that is attributable to such additional benefits shall be separately specified.

Now what are these four levels. Let us start at the end, the Premium Plus. This is the Union Plan, the payback to the Unions for ensuring the election of the current President. They are now immortalized into law! You cannot make this up.

  1. Now back to Basic. This is the minimum coverage with the maximum payment.
  1. Enhanced is the minimum coverage with a minimum payment.
  1. Premium is the maximum coverage with maximum payment.
  1. Then we are back to the gold plated Union Plans. Affordable only by companies who will NOT be competing in a world economy, like….well like the Government…and most likely no other company which will survive.

Now how ill this be paid for. The answer is as follows:

(4) DIRECT PAYMENT OF PREMIUMS TO PLANS.—Under the enrollment process, individuals enrolled in an Exchange-partcipating health benefits plan shall pay such plans directly, and not through the Commissioner or the Health Insurance Exchange.

Now we are finally at the Public Plan:


(a) ESTABLISHMENT.—For years beginning with Y1, the Secretary of Health and Human Services (in this sub title referred to as the ''Secretary'') shall provide for the offering of an Exchange-participating health benefits plan (in this division referred to as the ''public health insurance option'') that ensures choice, competition, and stability of affordable, high quality coverage throughout the United States in accordance with this subtitle. In designing the option, the Secretary's primary responsibility is to create a low-cost plan without compromising quality or access to care.


(1) EXCLUSIVE TO THE EXCHANGE.—The public health insurance option shall only be made available through the Health Insurance Exchange.

(2) ENSURING A LEVEL PLAYING FIELD.—Consistent with this subtitle, the public health insurance option shall comply with requirements that are applicable under this title to an Exchange-participating health benefits plan, including requirements related to benefits, benefit levels, provider networks, notices, consumer protections, and cost sharing.

(3) PROVISION OF BENEFIT LEVELS.—The public health insurance option—

(A) shall offer basic, enhanced, and premium plans; and

(B) may offer premium-plus plans...

(g) ACCESS TO FEDERAL COURTS.—The provisions of Medicare (and related provisions of title II of the Social Security Act) relating to access of Medicare beneficiaries to Federal courts for the enforcement of rights under Medicare, including with respect to amounts in controversy, shall apply to the public health insurance option and individuals enrolled under such option under this title in the same manner as such provisions apply to Medicare and Medicare beneficiaries.

Thus the Public Plan will have elements like private plans, shall be run by the Government, people will be allowed to sue, and the Secretary and reporting Commissioner will decide what to offer and at what price.

In addition there is nothing in the Bill, HR 3200, to make this self supporting. Namely the Government may easily subsidize this Plan. The "level playing" field statement is ambiguous at the least and open to continuous litigation at the worst.

Now what does the Public Plan charge? The following details that:



(1) IN GENERAL.—The Secretary shall establish payment rates for the public health insurance option for services and health care providers consistent with this section and may change such payment rates in accordance with section 224.


(A) IN GENERAL.—Except as provided in subparagraph (B) and subsection (b)(1), during Y1, Y2, and Y3, the Secretary shall base the payment rates under this section for services and providers described in paragraph (1) on the payment rates for similar services and providers under parts A and B of Medicare.


(i) PRACTITIONERS' SERVICES.—Payment rates for practitioners' services otherwise established under the fee schedule under section 1848 of the Social Security Act shall be applied without regard to the provisions under subsection (f) of such section and the update under subsection (d)(4) under such section for a year as applied under this paragraph shall be not less than 1 percent.

(ii) ADJUSTMENTS.—The Secretary may determine the extent to which Medicare adjustments applicable to base payment rates under parts A and B of Medicare shall apply under this subtitle.

(3) FOR NEW SERVICES.—The Secretary shall modify payment rates described in paragraph (2) in order to accommodate payments for services, such as well-child visits, that are not otherwise covered under Medicare.

(4) PRESCRIPTION DRUGS.—Payment rates under this section for prescription drugs that are not paid for under part A or part B of Medicare shall be at rates negotiated by the Secretary.



(A) IN GENERAL.—The Secretary shall provide, in the case of services described in sub paragraph (B) furnished during Y1, Y2, and Y3, for payment rates that are 5 percent greater than the rates established under subsection (a).

(B) SERVICES DESCRIBED.—The services described in this subparagraph are items and professional services, under the public health insurance option by a physician or other health care practitioner who participates in both Medicare and the public health insurance option.

(C) SPECIAL RULES.—A pediatrician and any other health care practitioner who is a type of practitioner that does not typically participate in Medicare (as determined by the Secretary) shall also be eligible for the increased payment rates under subparagraph (A).

(2) SUBSEQUENT PERIODS.—Beginning with Y4 and for subsequent years, the Secretary shall continue to use an administrative process to set such rates in order to promote payment accuracy, to en sure adequate beneficiary access to providers, and to promote affordablility and the efficient delivery of medical care consistent with section 221(a). Such rates shall not be set at levels expected to increase overall medical costs under the option beyond what would be expected if the process under subsection (a)(2) and paragraph (1) of this subsection were continued.

(3) ESTABLISHMENT OF A PROVIDER NET WORK.—Health care providers participating under Medicare are participating providers in the public health insurance option unless they opt out in a process established by the Secretary.

(c) ADMINISTRATIVE PROCESS FOR SETTING RATES.—Chapter 5 of title 5, United States Code shall apply to the process for the initial establishment of payment rates under this section but not to the specific methodology for establishing such rates or the calculation of such rates.

(d) CONSTRUCTION.—Nothing in this subtitle shall be construed as limiting the Secretary's authority to correct for payments that are excessive or deficient, taking into account the provisions of section 221(a) and the amounts paid for similar health care providers and services under other Exchange-participating health benefits plans.

(e) CONSTRUCTION.—Nothing in this subtitle shall be construed as affecting the authority of the Secretary to establish payment rates, including payments to provide for the more efficient delivery of services, such as the initiatives provided for under section 224.

(f) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 224.

Finally the Public Plan will introduce many ways to practice Medicine such as bundling and the Medical Home construct. The opening part of the enabling legislation in HR 3200 is the most telling here. This is accomplished in the following parts:


(a) IN GENERAL.—For plan years beginning with Y1, the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers.

The above goes to the heart of the Government taking control over health care. They do:

1. Medical Home: This may have value for chronic patients.

2. Accountable Care Organizations

3. Value Based Purchasing

4. Bundling: This places hospitals in charge as we have argued before.

5. Differential Payments

6. Capitation: This was the procedure which HMOs used to ration and deny care!

These are the worst of the worst of the HMO era! They will in my opinion and in the opinion of many other practicing physicians destroy health care. It continues:

(b) REQUIREMENTS FOR INNOVATIVE PAYMENTS.— The Secretary shall design and implement the payment mechanisms and policies under this section in a manner that—

(1) seeks to—

(A) improve health outcomes;

(B) reduce health disparities (including racial, ethnic, and other disparities);

(C) provide efficient and affordable care;

(D) address geographic variation in the provision of health services; or

(E) prevent or manage chronic illness; and

(2) promotes care that is integrated, patient centered, quality, and efficient.

(c) ENCOURAGING THE USE OF HIGH VALUE SERVICES.—To the extent allowed by the benefit standards applied to all Exchange-participating health benefits plans, the public health insurance option may modify cost sharing and payment rates to encourage the use of services that promote health and value.

(d) NON-UNIFORMITY PERMITTED.—Nothing in this subtitle shall prevent the Secretary from varying payments based on different payment structure models (such as ac countable care organizations and medical homes) under the public health insurance option for different geographic areas.

Well that is it. Let us review the HR 3200 Exchange proposals:

1. Controlled by a Commissioner

2. Forces everyone to ultimately participate

3. Specifies what services are provided at what price.

4. Establishes a public plan with no parity with private plans, namely the Government can underwrite

5. Results in the elimination of Private Plans by word of law

6. Restructures any and all medical compensation into Government specified, controlled, prices, and allocated processes and procedures.

Exchange are worthwhile. They work well in free and open markets. Government controlled exchanges working under the letter of the law are a disaster. The overhead will cause irreparable harm to the citizens and destroy the US Medical community as we know it. Please just read the words. They were in my opinion written by an evil mind!

Childhood Obesity

There are two interesting posts that I will comment upon today. The first is a CDC post on Childhood Obesity. The second is a cost analysis of obesity in Health Affairs.

First the one on childhood obesity. I present the data in a somewhat different form than the CDC as below.

(i) CDC presents the 1998 stats on percent of 2-4 year olds in 1998. Note the variation between the states.

(ii) Now the percent of 2-4 year olds ion 2008. Now not the sudden upward explosion and the growth in certain states. New Jersey and Virginia have the largest prevalence in this data set.

(iii) Now the change in actual prevalence from 1998 to 2008. This is instructive but we use the following chart for better resolution.

(iv) Finally the percent change in prevalence in the same time period. This shows the explosive growth, appearing at 20% over this period. This is for 2-4 year olds! Not teenagers of older people. They will never get rid of this problem and this is the ticking time bomb of health care.

The CDC study states:

"The findings indicated that obesity prevalence among low-income, preschool-aged children increased steadily from 12.4% in 1998 to 14.5% in 2003, but subsequently remained essentially the same, with a 14.6% prevalence in 2008. Reducing childhood obesity will require effective prevention strategies that focus on environments and policies promoting physical activity and a healthy diet for families, child care centers, and communities."

Now for the Health Affairs report. It is by Finkelstein et al and it reports:

"In 1998 the medical costs of obesity were estimated to be as high as $78.5 billion, with roughly half financed by Medicare and Medicaid. This analysis presents updated estimates of the costs of obesity for the United States across payers (Medicare, Medicaid, and private insurers), in separate categories for inpatient, non-inpatient, and prescription drug spending. We found that the increased prevalence of obesity is responsible for almost $40 billion of increased medical spending through 2006, including $7 billion in Medicare prescription drug costs. We estimate that the medical costs of obesity could have risen to $147 billion per year by 2008..."

Their approach is dramatically different than our, in our Diabetes White Paper, where we stated:

"... demonstrates the potential impact an economic control of behavior can have in reducing a major health care cost. Type 2 Diabetes is caused by obesity in almost all cases. It currently, in 2008 costs, accounts for almost $275 billion annually or 12% of all health care costs. We estimate that by 2020 it will account for 25% of health care costs and is growing at 10-11% per annum. It is possible to control this at the source by taxing "carbs" as we have taxed tobacco. This paper presents the case from the perspective of the medical evidence, costs factors and economic control models."

In our approach we did a bottom up analysis based upon prevalence and incidence of disease states and costs per year per disease state. The Finklestein approach was performed by a statistical study of patients. Although they are half of our value they we fell justify the numbers we have arrived at. Clearly Type 2 Diabetes is and will explode as a major driver for health care costs. The Medical Home approach just institutionalizes this. We still firmly believe that the solution is via some form of controlling taxation as was done with tobacco.

Monday, July 27, 2009

The Portfolio

The standard portfolio we have been tracking is doing quite well. Perhaps with Congress in deadlock and their vacations coming up the market felt that perhaps nothing will happen, good thing perhaps. Just look what happened to the market when they passed the stimulus bill. Maybe there is something in this chart.

Sunday, July 26, 2009

Arrow, Krugman, Health Care and Plumbers

I once worked with a fellow who told me a tale about his father the plumber and the service business. The tale went this way. The plumber, his father, was called to a home for a blocked up toilet. It was late one evening and perhaps the home owner had eaten what he should not have, but alas, the toilet presented an infinite obstacle. So into the home goes the plumber, cost being no obstacle, and in this emergency he entered the bathroom, closed the door, used his plunger a few times, and then sat back, had a cigarette, in those days you could, read the newspaper, and after an hour he emerged and presented the home owner with a bill which the homeowner gratefully paid and slept well the remainder of the night.

The moral of this tale is that a plumber is in the service business, he does not advertise, he is a small businessman, he gets paid for the "service" he provides, not the complexity of the task, and his bill may be greater the greater the emergency.

The homeowner did not have a Government supplied Plumber Care Plan, the home owner did not have some right to Plumber Care, yet somehow the plumber got paid. I would hazard to guess that plumbers in today's market net more per year in take home, per hour, than pediatricians, internists, or psychiatrists. Perhaps not as much as a cardiologist, but their crafts have a great deal in common.

Krugman in his NY Times blog makes the following statement:

"There are two strongly distinctive aspects of health care. One is that you don’t know when or whether you’ll need care — but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor’s office; and very, very few people can afford to pay major medical costs out of pocket..."

I dare say this applies to plumbers, electricians, even dare I say lawyers. They are all in the service business, almost all independent and you never know when you need them but when you do they better be there. He continues:

"This tells you right away that health care can’t be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up
making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can’t just trust insurance companies either — they’re not in business for their health, or yours."

Well plumbing, electrical work, legal representation also is NOT sold like bread Mr. Krugman, but you as a strong liberal may not be aware of the working man.

Also you purchase auto and home insurance. You select the coverage you want. Take an umbrella policy, you get to buy one just in case your home liability is exceeded in some special circumstance. You do the same with auto. The state specifies a minimal level of liability but you almost always increase that plus if your car is not too old you add comprehensive. You never know when there is some accident. People buy their own insurance, albeit mandated in part, all over this country, and the world. In addition until the Government caused health care to be an employee "right" due to their wage and price controls, it was an individual responsibility, and did have insurance at the individual level for catastrophic illnesses. Thus Mr. Krugman's statements in my opinion are false at face value.

He continues:

"The second thing about health care is that it’s complicated, and you can’t rely on experience or comparison shopping. ...That’s why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners."

But the plumber is the very same. You want to do your own plumbing, electrical work, legal representation. Remember the old adage "A defendant who has himself as his lawyer has a fool for a client..." well Mr. Krugman it applies to a lot more than medicine.

Mr. Krugman opens the piece with the reference to Ken Arrow, Uncertainty and the Welfare Economics of Health Care. Arrow states the following special characteristics of health care:

"A. The Nature of Demand The most obvious distinguishing characteristics of an individual's
demand for medical services is that it is not steady in origin as, for example, for food or clothing, but irregular and unpredictable..."

My simple answer is look at the plumber. Look at the lawyer. Look at the electrician. There are lots of things out there that are the same in demand as health care.

"B. Expected Behavior of the Physician: It is clear from everyday observation that the behavior expected of sellers of medical care is different from that of business men in general. These expectations are relevant because medical care belongs to the category of commodities for which the product and the activity of production are identical."

So what are lawyers, chopped liver! There are hundreds of professions, accountants to name another, where the product and the activity are the same. The definition is the personal services industry, it even has an SIC code! But this was an 1963 article, in the days of Galbraith, where economists viewed the world as large corporations against the common man! Prof Arrow in my opinion is outright wrong. I even did electrical work in 1963! He continues:

"C. Product Uncertainty: Uncertainty as to the quality of the product is perhaps more intense
here than in any other important commodity. Recovery from disease is as unpredictable as is its incidence. In most commodities, the possibility of learning from one's own experience or that of others is strong because there is an adequate number of trials."

It is clear that Prof Arrow never went to a civil or criminal trial, especially with a jury. Remember the OJ Simpson trial! Oh yes, which one?

It is not worth continuing except to reiterate the Krugman comment at the beginning of his blog:

"One of the most influential economic papers of the postwar era was Kenneth Arrow’s Uncertainty and the welfare economics of health care, which demonstrated — decisively, I and many others believe — that health care can’t be marketed like bread or TVs."

Well Mr Krugman, it is my belief that Prof Arrow may have been culturally impaired due to his lack of exposure to plumbers and electricians. The argument lacks merit and the Krugman rant does likewise.

Medical Home: Euphemism for Rationing?

HR 3200 is rant with Government controls. I did not realize how much until I have spent days reading it. Every special interest, every wacko Congressperson, every fringe player have had their chance at throwing something in this festering soup. Today we talk of the Medical Home. Nice sounding name, is it not? But beware.

In a CNN, of all places, web piece by Shawn Tully, the author lists five areas of major concern in the health bills. Some are spot on and some are open for interpretation. Yet hidden in the middle of the article is the following:

"The Senate bill requires that Americans buying through the exchanges -- and as we've seen, that will soon be most Americans -- must get their care through something called "medical home." Medical home is similar to an HMO. You're assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.

Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. It was consumer outrage over despotic gatekeepers that made the HMOs so unpopular, and killed what was billed as the solution to America's health-care cost explosion."

Before commenting let us present the Bill and its wording. We use HR 3200 since I have been studying that at length. The Bill states:


TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS Sec. 1302. Medical home pilot program.


(a) IN GENERAL.—Title XVIII of the Social Security Act is amended by inserting after section 1866D, as inserted by section 1301, the following new section:



‘‘(1) ESTABLISHMENT OF PILOT PROGRAM.— The Secretary shall establish a medical home pilot program (in this section referred to as the ‘pilot program’) for the purpose of evaluating the feasibility and advisability of reimbursing qualified patient-centered medical homes for furnishing medical home services (as defined under subsection (b)(1)) to high need beneficiaries (as defined in subsection (d)(1)(C)) and to targeted high need beneficiaries (as defined in subsection (c)(1)(C))."

Now you must begin to parse the words. They are important. We will get to defining a Medical Home in a moment but read the enabling legislation. It is:

1. a pilot program

2. Targeted, and that I believe is an operative word, to (i) high need beneficiaries and (ii) targeted high need beneficiaries. Frankly I do not see the difference other than the word targeted, but wait, the Bill defines these terms.

The Medical Home pilot will do the following:

"‘‘(3) MODELS OF MEDICAL HOMES IN THE PILOT PROGRAM.—The pilot program shall evaluate each of the following medical home models: ‘‘(A) INDEPENDENT PATIENT-CENTERED MEDICAL HOME MODEL.—Independent patient centered medical home model under subsection (c). ‘‘(B) COMMUNITY-BASED MEDICAL HOME MODEL.—Community-based medical home model under subsection (d)."

Now to the Definitions:

‘(b) DEFINITIONS.—For purposes of this section: ‘

‘(1) PATIENT-CENTERED MEDICAL HOME SERVICES.—The term ‘patient-centered medical home services’ means services that—

‘‘(A) provide beneficiaries with direct and ongoing access to a primary care or principal care by a physician or nurse practitioner who accepts responsibility for providing first contact, continuous and comprehensive care to such beneficiary;

‘‘(B) coordinate the care provided to a beneficiary by a team of individuals at the practice level across office, institutional and home settings led by a primary care or principal care physician or nurse practitioner, as needed and appropriate;

‘‘(C) provide for all the patient’s health care needs or take responsibility for appropriately arranging care with other qualified providers for all stages of life;

‘‘(D) provide continuous access to care and communication with participating beneficiaries;

‘‘(E) provide support for patient self-management, proactive and regular patient monitoring, support for family caregivers, use patient-centered processes, and coordination with community resources;

‘‘(F) integrate readily accessible, clinically useful information on participating patients that enables the practice to treat such patients comprehensively and systematically; and

‘‘(G) implement evidence-based guidelines and apply such guidelines to the identified needs of beneficiaries over time and with the intensity needed by such beneficiaries.

‘‘(2) PRIMARY CARE.—The term ‘primary care’ means health care that is provided by a physician or nurse practitioner who practices in the field of family medicine, general internal medicine, geriatric medicine, or pediatric medicine.

‘‘(3) PRINCIPAL CARE.—The term ‘principal care’ means integrated, accessible health care that is provided by a physician who is a medical subspecialist that addresses the majority of the personal health care needs of patients with chronic conditions requiring the subspecialist’s expertise, and for whom the subspecialist assumes care management."

"‘‘(B) COMMUNITY-BASED MEDICAL HOME DEFINED.—In this section, the term ‘community-based medical home’ means a nonprofit community-based or State-based organization that is certified under paragraph (2) as meeting the following requirements:
‘‘(i) The organization provides beneficiaries with medical home services.

‘‘(ii) The organization provides medical home services under the supervision of and in close collaboration with the primary care or principal care physician or nurse practitioner designated by the beneficiary as his or her community-based medical home provider.

‘‘(iii) The organization employs community health workers, including nurses or other non-physician practitioners, lay health workers, or other persons as determined appropriate by the Secretary, that assist the primary or principal care physician or nurse practitioner in chronic care management activities such as teaching self-care skills for managing chronic illnesses, transitional care services, care plan setting, medication therapy management services for patients with multiple chronic diseases, or help beneficiaries access the health care and community-based resources in their local geographic area."

In some ways this is starting to sound like the old Public Health system of the 1920s and 1930s. Now to the high need beneficiary we spoke about above:

‘‘(C) HIGH NEED BENEFICIARY.—In this section, the term ‘high need beneficiary’ means an individual who requires regular medical monitoring, advising, or treatment. "

In a way this is the chronically ill, the Type 2 Diabetic, the congestive heart failure, the patient with COPD. It seems not to include the cancer patient, the broken leg, or even the day to day practice of medicine. It seems targeted at those who frankly use most of the health care facilities by their continuing return to them.

The program will be evaluated on the following:


‘‘(1) EVALUATION OF COST AND QUALITY.— The Secretary shall evaluate the pilot program to determine—

‘‘(A) the extent to which medical homes result in—

‘‘(i) improvement in the quality and coordination of health care services, particularly with regard to the care of complex patients;

‘‘(ii) improvement in reducing health disparities;

‘‘(iii) reductions in preventable hospitalizations;

‘‘(iv) prevention of readmissions;

‘‘(v) reductions in emergency room visits;

‘‘(vi) improvement in health outcomes, including patient functional status where applicable;

‘‘(vii) improvement in patient satisfaction;

‘‘(viii) improved efficiency of care such as reducing duplicative diagnostic tests and laboratory tests; and

‘‘(ix) reductions in health care expenditures..."

The patient concerns is seventh. But frankly the intent is not bad. It takes those patient who often dominate the costs, in almost all cases there is an existing diagnosis and course of the disease, and manages it. This is a patient management system. If you have Type 2 Diabetes they will try to manage you. If you have COPD the same applies. You may live a long time but the way it is managed now you may be seeing dozens of physicians and wasting resources. Is this rationing? Frankly I think not. It is good sense. It also is a trial.

And now how much will this cost? Well the Bill states:

‘‘(1) OPERATIONAL COSTS.—For purposes of administering and carrying out the pilot program (including the design, implementation, technical assistance for and evaluation of such program), in addition to funds otherwise available, there shall be transferred from the Federal Supplementary Medical Insurance Trust Fund under section 1841 to the Secretary for the Centers for Medicare & Medicaid Services Program Management Account $6,000,000 for each of fiscal years 2010 through 2014. Amounts appropriated under this paragraph for a fiscal year shall be available until expended.

‘‘(2) PATIENT-CENTERED MEDICAL HOME SERVICES.—In addition to funds otherwise available, there shall be available to the Secretary for the Centers for Medicare & Medicaid Services, from the Federal Supplementary Medical Insurance Trust Fund under section 1841—

‘‘(A) $200,000,000 for each of fiscal years 2010 through 2014 for payments for medical home services under subsection (c)(3); and

‘‘(B) $125,000,000 for each of fiscal years 2012 through 2016, for payments under subsection (d)(5). Amounts available under this paragraph for a fiscal year shall be available until expended."

That is only a bit shy of $2 billion. Peanuts!

So let's go back to the CNN article. Our approach has been to deal with the facts. The Medical Home is a Medicare Trial, and a worthwhile one indeed if it stays to the chronically ill. The author of the CNN article seems to imply that this Trial applies to all! I cannot find that in HR 3200. This continues a problem I have with the media, they fail to reference the specific statement, the words, and then they go off in a screaming tangent. Upon my first reading of the CNN piece I thought there would be fire here amongst the smoke. No, sorry, it may even be a great idea!

Type 2 Diabetes and Fattys

In a recent article in Science the author does a wonderful job in providing an up to date review of just where the research is on Type 2 Diabetes and obesity.

The author concludes:

"One observation that seems indisputable is that when individuals lose weight, they become more insulin sensitive. If nothing else, this has given researchers the confidence to assume that excess body fat—particularly in the abdomen and around the internal organs— is a fundamental cause of insulin resistance. But that still avoids the question of what causes insulin resistance in lean individuals. This is something few researchers will even address, although one possibility is that they, too, simply can’t store fat safely in subcutaneous pads.

“The biggest question in the whole field of insulin resistance is still this direction of causality,” says O’Rahilly. “Does obesity make you insulin resistant? Or does underlying factor x cause both obesity and insulin resistance?”"

Yet the remaining fact is that Type 2 Diabetes is prevalent in obese people 100 to 1 more times in those not and the article does articulate the fact that fat is the primary cause of inflammation which in turn is a causative factor in the insulin collapse chain.

Saturday, July 25, 2009

What Side is Peggy Noonan On?

I confess that I am not a follower of Peggy Noonan, she tends to be a bit too much, but alas seeing the title of the most emailed article on the WSJ on health care I clicked and there I was smack dab in the middle of a Noonan article.

Now as some of you may know I have gathers some knowledge on health care over the past 42 years, not enough ever to practice, God forbid, I like the disease more than the patient, a kind of Dr House persona, but at least I think I know a bit.

Now Noonan makes several points:

1. First she states "make it illegal for a doctor not to charge or a hospital to fudge around, with mercy, in its billing" but the point is not billing nothing and not charging but billing and ever collecting. One will always have a bad bunch who over bill, but for the most part physicians are the most honest people I know. Just look at the alternative, bankers and politicians, and I live in New Jersey, here they pols make the Mafia look like Mother Theresa!

2. The Bill does "allow for or mandate taxpayer funding of abortion" and this of course is a hot button, it is an in your face from the left wing Democrats. Yet the Bill gives an option for Christian Scientists to seek their own treatment from Practitioners and Nurses. This inclusion was really dumb on the part of the Dems, primarily because there are so many Catholic Hospitals and this would drive them out of existence. I know that Catholics are not well thought of, being one, but why eliminate what they do that has great value. There were ways to allow this without mandating. But again and alas it was the in your face politics from the left wing Dems.

3 This I totally disagree with! She states "educated people who are at the top of American life feel they have the right to make very public criticisms of . . . let’s call it the private, pleasurable but health-related choices of others..." She continues "Under a national health-care plan we might be hearing that a lot. You don’t exercise, you smoke, you drink, you eat too much, and “the rest of us have to pay for it.”" Now here I depart. I depart strongly. If you were to drive drunk, text all the time, and do so at 90 mph, then I want you not only to pay more for your insurance but I want you off the road, period. If you are a fatty, smoke, and fail in general to care for yourself, and we have a universal plan, then I want you to either stop or pay more.

Now look at the new Surgeon General, a bit over the limit. Now look at the web site of the Surgeon General. It has a page on childhood obesity and a pledge that it asks children to sign. The Surgeon General letter for children states:

"Help Prevent Childhood Overweight and Obesity and Secure a Healthy Future for our Children

Today, more than 12.5 million children – 17 percent of children and adolescents ages 2 to 19 -are overweight. Teaching children the importance of healthy eating and physical activity at a young age is necessary to help prevent overweight and obesity in this country. Together we can make a difference.

As Surgeon General, I ask you to join this movement to help children achieve and maintain a healthy weight by making this promise:

Surgeon General’s Pledge

I pledge to:

  • Be a role model by making healthy choices for myself.
  • Help children be physically active through everyday play and participation in sports.
  • Support children’s healthy eating habits.

A healthy future is our gift to our children.


One may very well ask if this pledge will be removed when the new Surgeon General arrives. One of her parents allegedly died of Diabetes and she appears to be obese if not morbidly so. Yes Ms. Noonan, people in glass houses, well not quite that aphorism! But you get the point.

New Book on Health Care Policy

I have just posted a book called Health Care Policy: Politics vs Reality, a draft, which is an edited compilation of my White Papers since January. You may find it of interest since it places all of the factors on the table.

I especially enjoy my comments on Medicare. I state:

There have been many arguments that Medicare is broken. We will show here that such a
statement is far from the truth. Indeed Congress is broken and is literally stealing money
from Medicare. We will do this with a simple example.

"1. Assume that a person starts work in 1970 at the salary of $16,000 per year. They get
raises of 5% per year until they retire at 65 in 2005. Their final salary is $107,000 per

2. Each year they have contributed 3% of their gross salary to the Medicare fund. That is
gross with no cap. Assuming the fund invests the contribution at an average 6% rate for
that period and it is compounded then in 2005 they have $165,000.

3. Now they retire at 65 and they have an actuarial life of 12 more years. Medicare costs
an average of $12,000 per year as we show below. The net present value of these 12
payments of $12,000 is $100,000.

4. But, and this is an important BUT, they have contributed $65,000 more than they will
ever collect! Where did the money go? Congress spent it!

5. This gets worse the more you make. In the following chart we show how the
contribution explodes as salary explodes. Remember the costs are the 12 years times
the $12,000. They are the same for everyone. The more you make the more the
Government collects."

I think all those at or near Medicare age should think of this fact. You more than paid for it and Congress just appropriated your money for themselves!

We are Busy in the Garden

We are in the garden doing hybridizing. It means up at 4:30, watch out for the deer, keep the fences in tact, choose the plants, get the pollen before the bees do, do the crosses, enter the data, take the photos, enter the data, post to the web, and resort the data. A metaphor for life. But at the end we get new and beautiful hybrids.

The subtlety of color, the complexity of the patterns and the softness of the petals. Just thought I give all a break! After all Congress will be adjourning before they decide on health care, good idea!

Wednesday, July 22, 2009

Quality, HR 3200, and The Meaning of Life, Literally!

I have written about quality in health care a few weeks ago and have just published a White Paper on health care quality. In reading HR 3200 I see that they too have included quality. In fact the Bill is called:

H. R. 3200 ‘‘America’s Affordable Health Choices Act of 2009’’ "To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes."

Now as we have said before quality is truly in the eye of the beholder, in this case the patient. If one has prostate cancer, quality care is not lots of morphine and just letting it met to the bone. Quality is engaging the patient in the process of managing his disease. Each patient is different, each patient has a different world view. Some dread incontinence, some sexual dysfunction, some pain. Thus the treatment of a patient, quality treatment, is a personalized interaction between patient and physician.

In HR 3200 they introduce sections defining as best as a politician can the idea of quality. It starts as follows:

"H. R. 3200 ‘‘America’s Affordable Health Choices Act of 2009’’.



Subtitle C—Quality Measurements


Title XI of the Social Security Act, as amended by section 1401(a), is further amended by adding at the end the following new part:


(a) ESTABLISHMENT OF NATIONAL PRIORITIES BY THE SECRETARY.—The Secretary shall establish and periodically update, not less frequently than triennially, national priorities for performance improvement.

‘‘(b) RECOMMENDATIONS FOR NATIONAL PRIORITIES.—In establishing and updating national priorities under subsection (a), the Secretary shall solicit and consider recommendations from multiple outside stakeholders.

‘‘(c) CONSIDERATIONS IN SETTING NATIONAL PRIORITIES.—With respect to such priorities, the Secretary shall ensure that priority is given to areas in the delivery of health care services in the United States that—

‘‘(1) contribute to a large burden of disease, including those that address the health care provided to patients with prevalent, high-cost chronic dis eases;

‘‘(2) have the greatest potential to decrease morbidity and mortality in this country, including those that are designed to eliminate harm to patients;

‘‘(3) have the greatest potential for improving the performance, affordability, and patient centeredness of health care, including those due to variations in care;

‘‘(4) address health disparities across groups and areas; and

‘‘(5) have the potential for rapid improvement due to existing evidence, standards of care or other reasons."

It then goes on to define quality as follows:

"‘‘(d) DEFINITIONS.—In this part:

‘‘(1) CONSENSUS-BASED ENTITY.—The term ‘consensus-based entity’ means an entity with a contract with the Secretary under section 1890. ‘

‘(2) QUALITY MEASURE.—The term ‘quality measure’ means a national consensus standard for measuring the performance and improvement of population health, or of institutional providers of services, physicians, and other health care practitioners in the delivery of health care services...."

This is a deadly definition of quality. It is akin to what the Brits have in their national system where they use the QALY approach to the rationing of health care. The QALY approach looks at a disease and looks at the average quality of life for a variety of treatments. For example we consider prostate cancer. There are three treatments; do nothing, prostatectomy, radiation therapy. Each of these has an outcome and has a patient result in quality of life measurements. Thus is we consider the quality measures some weighted average of pain, sexual dysfunction and incontinence, then we get a quality measure for each treatment for each period of time after diagnosis. We then obtain the average across the country and see that for example doing nothing may have the least impact, the patient has longer time with no sexual dysfunction and incontinence and they die faster so the time with pain is less. Then we assign a cost. Doing nothing is cheap, just lots of morphine if the Government even allows that. The Brits then rank each treatment by the $/QALY and permit the lowest cost treatment only! That means often doing nothing!

But what is wrong with this you may ask, for Congress has in effect placed this in the new Bill! What is wrong is that every patient is different and we are assuming the average. If you are average then you get the correct treatment. If you are not then you are mistreated.

Parsing the above definition is telling. Let us proceed:

1. "national consensus": this means an average across all and disregard to the individual. Medicine is a profession which deals with persons, individuals, and not large groups. Each person with prostate cancer is different. However the Congress drives this to an average. The Brit's QALY approach is just that, an average. God forbid if your disease is one sigma either way, the plan drives to the mean.

2. "performance and improvement of population health" This is NOT individual health, not individual quality, but the population as a whole, as an average. This takes the practice of Medicine and throws it out the door. Why take patient histories, just do a test, diagnose the disease, and use what is in column A. Why perhaps we do not need physicians, that good old obese GS 10 can handle it all on their own!

3. "or of institutional providers of services, physicians, and other health care practitioners" This again focuses on the delivery, and one suspects the costs of the delivery. If we make them all size 10. I remember the tale a fellow grad student told me at MIT. He lived on a Kibbutz and he was 6" 5" and had a size 14 shoe. The Kibbutz only had size 6 thru 10 shoes. He never got shoes because he was outside the range that was acceptable in the Kibbutz. Thus he move to the States where he could get shoes. In the HR 3200 plan it assumes that the delivery will be those size 6-10 shoes and God forbid if you have a 14 foot, You die!

The Bill then continues:



‘‘(1) IN GENERAL.—The Secretary shall enter into agreements with qualified entities to develop quality measures for the delivery of health care services in the United States.

‘‘(2) FORM OF AGREEMENTS.—The Secretary may carry out paragraph (1) by contract, grant, or otherwise.

‘‘(3) RECOMMENDATIONS OF CONSENSUS BASED ENTITY.—In carrying out this section, the Secretary shall—

‘‘(A) seek public input; and

‘‘(B) take into consideration recommendations of the consensus-based entity with a contract with the Secretary under section 1890(a).


—Consistent with the national priorities established under this part and with the programs administered by the Centers for Medicare & Medicaid Services and in consultation with other relevant Federal agencies, the Secretary shall determine areas in which quality measures for assessing health care services in the United States are needed.


‘‘(1) PATIENT-CENTERED AND POPULATION BASED MEASURES.—Quality measures developed under agreements under subsection (a) shall be designed—

‘‘(A) to assess outcomes and functional status of patients;

‘‘(B) to assess the continuity and coordination of care and care transitions for patients across providers and health care settings, including end of life care;

‘‘(C) to assess patient experience and patient engagement;

‘‘(D) to assess the safety, effectiveness, and timeliness of care;

‘‘(E) to assess health disparities including those associated with individual race, ethnicity, age, gender, place of residence or language;

‘‘(F) to assess the efficiency and resource use in the provision of care;..."

Finally the Bill defines the Stakeholders who will assist in the definitions. It states:


‘‘(6) MULTI-STAKEHOLDER GROUPS.—For purposes of this subsection, the term ‘multi-stakeholder groups’ means, with respect to a quality measure, a voluntary collaborative of organizations representing persons interested in or affected by the use of such quality measure, such as the following:

‘‘(A) Hospitals and other institutional providers.
‘‘(B) Physicians.
‘‘(C) Health care quality alliances.
‘‘(D) Nurses and other health care practitioners.
‘‘(E) Health plans.
‘‘(F) Patient advocates and consumer groups.
‘‘(G) Employers.
‘‘(H) Public and private purchasers of health care items and services.
‘‘(I) Labor organizations.
‘‘(J) Relevant departments or agencies of the United States.
‘‘(K) Biopharmaceutical companies and manufacturers of medical devices.
‘‘(L) Licensing, credentialing, and accrediting bodies."

Does anyone notice who is missing from this list? The patient. There should be one and only one advocacy group and that should and must be the patient. The patient along with their physician should decide. Not some gang from Washington or the south side of Chicago!

Who (what) is a patient advocacy group? It is some political organization whose sole purpose is its own continuation. They, the Government, have all of these "stakeholders", entities interested in lining their own nests and pockets, but the poor patient is left out in the cold. Remember this bill looks at the average patient, not even plus or minus one standard deviation. The arrogance of assembling this group of people is an insult to the American patients who as taxpayers are paying for this collections of lobbyists. This Bill is a full employment Bill for Lobbyists!

Finally the Bill advocates the use of these measures as follows:


(a) INPATIENT HOSPITAL SERVICES.—Section 1886(b)(3)(B) of such Act (42 U.S.C. 1395ww(b)(3)(B)) is amended by adding at the end the following new clause:...


(I) Subject to subclause (II), for purposes of reporting data on quality measures for inpatient hospital services furnished during fiscal year 2012 and each subsequent fiscal year, the quality measures specified under clause (viii) shall be measures selected by the Secretary from measures that have been endorsed by the entity with a contract with the Secretary under section 1890(a).

‘‘(II) In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical quality measure has not been endorsed by the entity with a contract under section 1890(a), the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. The Secretary shall submit such a non-endorsed measure to the entity for consideration for endorsement. If the entity considers but does not endorse such a measure and if the Secretary does not phase-out use of such measure, the Secretary"

Finally we have the Secretary of HHS selecting the quality measures! Health care is now a fully political process!You cannot make this up. The poor patient is thrown onto the ash heap of politics and their health care is reduced to political whims!