Patient Dumping, the BBC, and Health Care Reform in 2008

It's always nice to get an outside perspective on things when trying to make a major decision. This is true of just about everything. Today we are going to take a look at California health care, and we are going to do so though the eyes of the BBC.

It is no secret that the cost factor is mammoth when it comes to medical care in the United States. It is the factor that prevents lower income people from seeking medical aid until they cannot afford it. Numerous emergency room trips are made every day by uninsured people who have finally decided that their health issue du jour has gotten bad enough to force them to seek help.

This subject, and the brutal way in which it is handled sometimes, is presented in a very striking fashion by David Willis, the Los Angeles correspondent for BBC News:

Skid Row in downtown Los Angeles encompasses 50 square blocks of the city and is home to about 800 people sleeping rough.

Some, with no health insurance and no home, were literally dumped there by hospitals because they could not pay the bill.

He converses with Reverend Andy Bates who runs a mission in the area and has documented over a hundred cases of "Patient Dumping" in the skid row area over the past year and a half.

He told me: "I've seen a lot on these streets, but nothing compares to the woman who was dropped off in a hospital gown, an [intravenous drip] still in her arm, who died 10 minutes later in our reception area of pneumonia - discharged simply because she couldn't afford to pay her hospital bill."

If anyone still needs further proof that the health care system in this nation needs to be reformed immediately this should prove sufficient. Best wishes for your health and for health care reform in the New Year.

George Williams
Blogmaster, Health Care Reform Now
http://healthcarereformnow.blogspot.com

SOURCE: "Healthcare for all in California?" 12/27/07
photo courtesy of efouche

Federal Judge Says "No" To Employer Mandates in San Francisco

The gavel has fallen.

Today a United States federal judge has struck down a basic component of the ambitious San Francisco health care plan. The court ruled that employers cannot legally be forced to subsidize the plan. Lisa Leff of the Associated Press brings us the details:

U.S. District Judge Jeffrey White ruled Wednesday that the mandate, set to take effect on Jan. 1, would violate a 1974 federal law requiring consistency in the health coverage afforded employees who work for the same company but live in different jurisdictions.

"By mandating employee health benefit structures and administration, those requirements interfere with preserving employer autonomy over whether and how to provide employee health coverage, and ensuring uniform national regulation of such coverage," White wrote.

The ruling came in a lawsuit brought by the Golden Gate Restaurant Association, which argued that the mandatory contributions the city sought placed a costly burden on members already struggling to make a profit.

Healthy San Francisco, as the plan is called, was developed to provide access to health care for the city's poorest. The goal is to give 82,000 people access to clinics and medical services no matter what their employment or immigration status is. At this point 6,500 people are signed up for the program which began last July.

The estimated financial outlay for the plan is $200 million per year. To offset the expense city officials passed a law stating that:

Companies with 20 or more workers to spend at least $1.17 per hour toward each employee's health care. Those with more than 100 workers would have to pay $1.76 per hour up to a monthly maximum of $180 per worker.

Whichever way the appeal goes, this is going to be a very important case to watch for all of us who are concerned with the path of universal health care in the United States.

SOURCE: "Part of S.F. Health Care Plan Tossed Out" 12/27/07
photo courtesy of Brymo

Health News for the Holidays

While we were off enjoying the yuletide holidays the world of health care did not sit still. Since it has been a few days since we've been able to provide you with informative reading material, it is time for another quick roundup of some interesting and important stories from the past few days.

First stop: Melville, New York. Kathleen Kerr over at Newsday brings us tidings of the decade-old MDNY Healthcare, an HMO, which has just announced that it is going out of business. As she points out, this is the latest in a string of ill news for the group:

In 1999, the insurance plan announced its withdrawal from the western New York marketplace, citing steep operating costs and $1 million in losses. A year later, MDNY was among 21 health insurers fined by the state Insurance Department for failure to pay claims promptly - the company paid $5,000.

Next comes a brilliant bit of holiday marketing from Highmark (you might remember that we wrote about these guys awhile ago) as they offer their new health care gift cards to the first newborns of the year in the company's home state of Pennsylvania (News Release). Notable is the fact that nowhere in their news release does it specify how many of the state's newborns will be gifted with the cards.

No news roundup would be complete without taking a quick glance at the contenders for U. S. President. In this arena the Democrats are still the ones dominating the news, mostly due to the growing venom between Democratic frontrunners Hillary Clinton and Barack Obama. If you have been reading our posts here on Health Care Reform Now! you will find no surprises. To mandate or not to mandate, that is the question.

David Nitikin's article for the Baltimore Sun brings us a nice breakdown of the mandate issue along with the the latest (familiar sounding) quotes:

Clinton mailed a letter to Iowa voters, over the signature of former Gov. Tom Vilsack, which says "Mr. Obama threw back talking points worthy of Rudy Giuliani or Mitt Romney" when questioned about "flaws" in his plan.

In response, Obama distributed a piece in New Hampshire that defended his health proposals and urged voters to "remind Hillary Clinton" that the Jan. 8 primary "won't be won by launching misleading, negative attacks."

SCHIP continues to be in the news over the holidays. Conservative blogger Jeff Emanual (Director of RedState.com, a widely read right wing blog) waxes almost gleeful at the defeat of the Democrat driven initiative to expand the program. This morning he shares that glee in a piece on HumanEvents.com:

Even more impressive than the majority party’s public surrender on SCHIP expansion was the speed and completeness of it. Less than a week after falling victim to Bush’s veto pen for a second time, the Senate had passed the fifteen-month extension by unanimous consent, and the House had approved it by a 411-3 vote.

The hysterical tenor of some floor speeches showed the Democrats’ desperation. “How many children will be dead” if the President were to veto the SCHIP expansion? asked Rep. Lloyd Doggett (D-TX).

Last, but very far from least is the ongoing saga of California's struggle to enact health care reforms. Rather than point you toward a single article, here is a link to the Google News results page on the subject. A wide variety of opinions and perspectives for your home researching pleasure.


SOURCE: "Melville HMO going out of business" 12/26/07
SOURCE: "Press Release: Highmark to Present State's Newest Residents with Healthcare Gift Cards " 12/24/07
SOURCE: "Clinton, Obama clashing on health
Democrats debate requiring people to buy coverage" 12/26/07
SOURCE: "SCHIP Expansion: Congressional Majority Surrenders Completely" 12/26/07
SOURCE: "Google News: California Health Care" 12/26/07
photo courtesy of bobcat rock, used under this Creative Commons license

Holiday Tidings: A Health Care Roundup

As we approach the New Year, it seems only appropriate to provide a roundup of health care coverage in the blogosphere.

To begin Alan Katz provides his own news roundup on the California health care initiative at the very informative Alan Katz Health Care Reform Blog:

A couple of days ago I provided links to documents, articles and web sites describing the Health Care Security and Cost Reduction Act passed by the Assembly on December 17th. Those were predominately focused on the facts surrounding ABX1-1. Now that folks have had a few days to look things over, opinions about the compromise health care reform package pulled together by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez are emerging. Here’s a round-up of some of the more interesting ones.

Katz has assembled an authoritative guide to who is saying what in regard to the controversial health care legislation that just passed he California Assembly.

Kathleen O'Connor over at the Code Blue Health Blog applauds the efforts of Washington State Governor Christine Gregoire's proposal to add 7.89 million dollars to increasing patient safety in her state. Once again the issues of transparency and accountability are brought to the fore.

The next stop on this virtual whirlwind tour is the Guest Blog section of HealthCommentary.org, where Michael L. Millenson, president of Health Quality Advisors LLC, draws upon Charles Dickens to deliver his own message on health care.

... a story rooted in the plight of a crippled young boy whose father cannot afford the care his son desperately needs. The prospect of Tiny Tim’s eminently preventable death finally breaks through Ebenezer Scrooge’s bitterness, causing the old miser to abandon his hard-hearted ways.

Alas, we Americans still seem inclined to treat the demand for universal health coverage like the Scrooge of old. His dismissive cry, “Are there no poorhouses?” is echoed by our smug assertions that those in dire medical need can “just go to an emergency room.”

As we leave Dickens and Millenson behind our next stop is the Health Care Renewal Blog where Dr. Roy M. Poses provides a handy scorecard of not only some of the commentators on health care, but also reveals interesting (and well documented) data about the business and ideological ties each of them bring to the table.

So there you have it, a variety of offerings from across the blogosphere. Our gift to you, as always, is food for thought. May your holidays -- however you celebrate -- be happy and healthy! We'll be back on December 26 with more Health Care Reform Now!

SOURCE: "Another California Health Care Reform Round-up" 12/20/07
SOURCE: "A Boon for Patient Safety" 12/19/07
SOURCE: "Tiny Tim Health Care: Dickens' Christmas Carol carries a health care message for all of us" 12/20/07
SOURCE: " You Can't Tell the (Health Care Policy Op-Ed) Players Without a Scorecard" 00/00/00

How To Save 88 Billion Dollars

Today the Health Care Reform Now! Blog is happy to share a multimedia extravaganza with our readers. The Commonwealth Fund's Commission on a High Performance Health System has released their report, Bending the Curve: Options for Achieving Savings and Improving Value in Health Spending, which shares savings estimates for 15 federal policy options over the next decade. The study examines the overall effect of many health care proposals put forth by the various U.S. Presidential candidates, as well as going into detail on the ramifications for all levels of government, average American households and private payers.

From the report's executive summary:

U.S. health spending is projected to increase from 16 percent of GDP in 2006 to 20 percent in 2016—from $2 trillion to $4 trillion. Meanwhile, the number of uninsured Americans continues to rise. In this report prepared for The Commonwealth Fund Commission on a High Performance Health System, the authors examine 15 federal policy options that have the potential to lower health spending relative to projected trends. They include policies that would: produce and use better information for health care decision-making, promote health and enhance disease prevention, align financial incentives with quality and efficiency, and correct price signals in health care markets. Combining policies would capture the synergistic benefits of individual changes. If implemented along with universal health insurance, a combination of selected options could save $1.5 trillion in national health expenditures over 10 years, while also improving value in terms of access, quality, and health care outcomes.

What does this have to do with multimedia you ask? To start off with here is a link to the video webcast of the report's unveiling which includes Commonwealth Fund President Karen Davis, Senior Commonwealth Fund Vice President Cathy Schoen, and President/CEO of the Employee Benefit Research Institute Dallas Salisbury as speakers.

For something a little bit more directly interactive the Commonwealth Fund team has thoughtfully provided an interactive matrix that will allow you to rapidly zero in on whatever particular aspect of the report most interests you. As you click through the various subheadings not only do you get a wealth of information, but also a striking array of graphs that present the data visually.

The report's executive summary contains not only all the raw data one would expect, but also a wide variety of PDFs that reconfigure the information in myriad ways for a variety of needs. The report itself and the executive summary are available as separate downloads, while the "chartpack," can be downloaded either as a PDF or as a PowerPoint Presentation. Many related publication and programs are also linked on this page as well. Whatever else you might say, The Commonwealth Fund makes it very easy to access their findings. This is only appropriate since one of their main assertions is that information technology is crucial as far as reducing overall costs is concerned:

Accelerate provider adoption of health information technology (HIT) with the capacity for decision support and to share patient health information across sites of care, financed by an assessment of 1 percent on insurance premiums and Medicare outlays. After initial investment costs, estimated net health system savings could reach $88 billion over 10 years as HIT capacity is improved. Net savings would accrue by year 10 to all except private payers, which would realize cumulative savings in following years.

(NOTE: Emphasis in the above quote is my own - GW)

SOURCE: "The Commonwealth Fund's Commission on a High Performance Health System"
SOURCE: "Bending the Curve: Options for Achieving Savings and Improving Value in Health Spending" 12/18/07
SOURCE: "Report Release On Estimated Savings From Specific Health Reform Options" 12/18/07
SOURCE: "Bending the Curve: Savings Matrix" 12/18/07
SOURCE: "Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending" 12/18/07
photo courtesy of Bending the Curve

Breadbasket or Basket Case?

This morning the Access Project, a nonprofit resource center based in Boston, Massachusetts, released a report that states that the cost of health insurance is a large and direct contributor to the financial problems of the average American farmer.

Cheryl Tevis, Farm Issues Editor of Successful Farming magazine, brings us her breakdown of the report today on the Agriculture Online website:

The report is the second in a series intended to inform the debate on health care reform. The first report showed that although the majority of farm and ranch operators have insurance, the triple-whammy of high deductibles, premiums and out-of-pocket costs leaves them under-insured when it comes to annual physical exams and preventive care...

"Family farmers and ranchers struggling to maintain their operations are not well served by the current health insurance marketplace," says Carol Pryor, lead author of the report and senior policy analyst at The Access Project. "We found that those purchasing coverage directly on the individual market pay the highest premiums for coverage that often leaves them financially exposed."

These findings are no surprise as they simply confirm what various studies have said about other demographics here in the United States, namely that the cost of health care is receding further and further from the reach of the average American, and that even if you are covered that is no guarantee that your coverage is up to the task if you face a major medical situation. The difference here is that most of the studies done so far focus on urban populations as opposed to rural ones.

The study produced several interesting results, among them were the following:

• Among those paying high premiums for insurance those with high deductibles paid 22% more than those with low deductibles.


• Factoring in age and health families buying insurance in the individual market rather than through an employer spent over $4,000 per year more on premiums


• For many the average overall health care expenses run between seven and eighteen percent of their yearly income.

Is our nation's breadbasket becoming a basket case? Is that quintessential archetype of the American landscape, The Farmer, in danger of being submerged in ivory waves of bills instead of tending amber waves of grain? This showcases another reason why health care reform is at the top of the American agenda.

SOURCE: "Health care costs slamming farm families: Study finds new measures needed to control costs" 12/19/07
photo courtesy of miheco, used under this Creative Commons license

California Nurse Say's "Pull The Plug"

Donna Gerber is displeased by the state of affairs in Sacramento, and when the Director of Government Relations for the California Nurses Association/National Nurses Organizing Committee is displeased she is not shy about it. Today she cut loose, using the California Progress Report, a progressive website, as her pulpit to let the powers that be know exactly what she thinks of current attempts at health care reform.

Comparing the rush to pass some form of health care legislation during this state legislative session with the rush to deregulate energy in the 1990's, she warns of hasty legislation with unforeseen consequences with the health care equivalent of rolling blackouts.

With the Assembly posed to vote Monday on the latest iteration of a sweeping bill, it is time to pull the plug. Let's step back, take action instead on an immediate health crisis and come back next year to enact a better, more comprehensive health reform plan that will actually solve our healthcare morass.

Thousands of California children now face the cutoff of coverage due to the President’s veto of the children's health program. Further, the governor is expected to propose emergency across the board budget cuts up to 10 percent as a result of the worsening budget deficit. We should all focus on guaranteeing continued coverage for children and protecting current programs rather than rushing through a bad plan that could just exacerbate the crisis for California families and the state.

AB1X, the health care reform bill she refers to, "will not be universal, it will not be affordable, it will not be of high quality, and bare bone plans with high out of pocket costs will be forced upon Californians and employers who will have no control over the price. This hardly seems to match up with what the pollsters say the people of California want." She drives her point home with facts, one after the other in rapid succession.

From the fact that wage garnishments will be enacted in some cases to ensure coverage to the simple fault that it does not guarantee affordable care to all Californians, the points she raises provoke and disturb. When compared to the stated goal of universal health care her list is an amazing array of loopholes, gaps, and counterintuitive elements; the lack of any limit on premiums or co-pays alone should raise eyebrows at the very least.

SOURCE: "Time to Pull the Plug on the Flawed California Health Care Deal" 12/17/07
photo courtesy of redking remixed and used under this Creative Commons license

The Health Care Rosetta Stone?

Yesterday we examined the amazing news that the VA health system has turned around, an about face brought on by the implementation of electronic medical records. The streamlining of procedure and upgrading of efficiency that resulted are proof positive that EMR's are one of the keys to ending our current health care crisis.

Today eMaxHealth looks at another facet of the issue in an article they titled "The Dirty Work of Health Care Information Technology." Using EMRs can eliminate a vast array of problems with the current system but like all computer programs they are only as good as the data put into them. An old saying among computer professionals is "garbage in, garbage out," and that is the point addressed here.

A study by researchers from the Regenstrief Institute, the Indiana University School of Medicine and the Indiana University School of Health and Rehabilitation Sciences, looked at hospital laboratories from five hospital systems in the Indiana Network for Patient Care and found that even in the same metropolitan area - Indianapolis and its suburbs - a variety of names were assigned to the same test - for example: complete blood count, hemogram and CBC.

As EMRs (hopefully) become more common across the health care industry this looms as a critically important element of reform. Currently only 5% of non-VA hospitals use EMR's, with cost of implementation often cited as the main reason for their absence. The fact that many of these digital systems are proprietary or use different coding for the various procedures they document isolates them from each other. Standardized naming conventions are absolutely crucial to using information technology to effect change.

What we need is a Rosetta Stone to translate them. To that end the Regestrief Institute of Indiana developed one over ten years ago: LOINC.

LOINC, the Logical Observation Identifiers Names and Codes database, acts as a universal standard of reference for laboratory and clinical data. In plain English it provides a common language for testing and results that can be correlated to the local test names creating a means of accurately translating from one "dialect" of health care terminology to another. As they put it on their own website:

...most laboratories and other diagnostic care services identify tests in these messages by means of their internal and idiosyncratic code values. Thus, the care system cannot fully "understand" and properly file the results they receive unless they either adopt the producer's laboratory codes (which is impossible if they receive results from multiple sources), or invest in the work to map each result producer's code system to their internal code system. LOINC codes are universal identifiers for laboratory and other clinical observations that solve this problem.

Could this be the Rosetta Stone we need to implement EMRs effectively? If this keeps up, we may some day have a common language that unites all health care providers, improving service across the board.

SOURCE: "The dirty work of health care information technology"
SOURCE: "Logical Observation Identifiers Names and Codes (LOINC®)"
photo courtesy of namlhots, used under this Creative Commons license

Best Health Care in The USA? Surprise! It's the VA!

The Veterans Administration, an organization that has been castigated for years on the subject of its low quality care, has made a turnaround. Be prepared, this story is replete with words and phrases that have gained a massive political charge in recent months, chief amongst them "socialized medicine."

ABC News brings us a thought provoking report (video here | text here ) on how the VA has moved from one of the worst health care programs in the country to being the best in the nation. I can sum it up in one phrase for you, electronic medical records. If you have the bandwidth I highly advise checking out the video linked above, if a picture is worth a thousand words then hundreds of them strung together as video should be worth millions.

Here are a few quick nuggets of data drawn from the text version online at the ABC News website:

Experts generally agree that electronic records are absolutely essential to significant health care reform. However, only about 5 percent of the nation's hospitals now have them.

[...] in most private hospitals 20 percent of lab tests are repeated simply because doctors can't find a patient's results.

But in the VA system, every patient's records are as close as a computer. It saves millions of dollars.

[...]Study after study puts the VA system at the very top for fewer medical errors, for effective treatments, for lower costs and for patient satisfaction. And the VA delivers all of this for at least $1,500 less per year per patient than Medicare.

Our own Mr. Halvorson is one of the experts who see electronic medial records (EMRs) as an essential part of the reform equation. The fact that the VA, has been implementing EMRs with such positive results supports the veracity of those claims. Granted, the VA system could not be implemented "as is" on a national basis, but the fundamental concept has now been proven to be sound. If a system of EMRs that follow each patient for their lifetime, as VA records do, is implemented nationwide, a significant potion of our current health care crisis can be averted.

SOURCE: "Veterans Affairs Healthcare System No. 1: How the Once-Maligned VA Healthcare System Becomes Best in Nation.
" 12/12/07
photo courtesy of scladesma, used under this Creative Commons license

A Libertarian Defense of Universal Coverage?

One way to get a person's attention is to hit him or her where it hurts: in the pocketbook. The average American's attention is now on health care reform for that exact reason. Over recent years, increases in the cost of insurance have far outstripped the pace of inflation and put the squeeze on the middle class and the working poor.

Today we will visit two sites in the Blogosphere that have definite opinions on the matter, each coming from different sides of the political spectrum. Lets start with the Daily KOS where the contributor known as HeartlandLiberal gives us a real world example of the rising expense of health care (Note: emphasis his):

This year the IMA medical services group here in Bloomington, IN, is threatening to withdraw from participation in the preferred provider program run by Anthem and used by Indiana University to manage its self-insured health care program through rational cost controls. They will withdraw unless they get a 23% increase in payment. THAT'S A DEMAND FOR A 23% INCREASE IN ONE YEAR.

Indiana University (IU) has a long and distinguished history of offering health care benefits well beyond the norm for the United States, even in the private sector. Click the link above to see the whole post as it includes a reproduction of the detailed memo sent to IU staff.

Then we bounce over to the other side of the ideological divide and visit the American Thinker web site where Randall Hoven, a self professed small government conservative/libertarian, offers a surprising argument in favor of universal health coverage along with detailed health care cost analysis.

The government provides Medicare for the old, Medicaid for the poor, veterans' hospitals for veterans, medical research funding and whatever else adds up to 6.6% of GDP. The federal government forces hospitals to provide emergency treatment to all comers. State governments mandate over 1,900 types of coverage on health insurance. Health care regulations cost the average household over $1,500.

We already have socialized medicine and we are already paying for it -- twice: once in taxes and once privately. What we are not getting is universal coverage.

But if universal care (via emergency rooms) is already mandated, what's the problem? First, it is not the best way to get treatment. For one thing, the condition has to be regarded as a medical emergency. Also, the law does not relieve you of having to pay for that treatment. In fact, medical bills are the leading cause of bankruptcies in the U.S., accounting for half of them.

So while you might not die, the U.S. health care system does give you the age-old offer of "your money or your life".

He presents a wide array of figures and documentation to back up his argument, giving lie to the idea that universal coverage is a left wing issue. As George Halvorson notes in his book, Health Care Reform Now!, universal coverage done right doesn't cost money, it saves money.

As an addendum, here's a link to the National Coalition on Health Care's document, Health Insurance Cost, an easy-to-read summary of health care costs based on 2005 data -- the most recent year for which data is available. Healthy reading!

SOURCE: "23% Increase Demand. Why We Need Health Care Reform" 12/11/07
SOURCE: "A Conservative Case for Universal Health Coverage" 12/12/07
SOURCE: "Health Insurance Costs"
photo courtesy of greefus groinks, used under this Creative Commons license

Missives From Massachusetts: Dogged By Paperwork

Time to take the pulse of health care reform in Massachusetts again as their universal health care plan is phased in. This time the Berkshire Eagle provides us with some views and interviews from the state's small businesses.

According to the state's new laws, every employer with eleven or more full time equivalent employees must offer a health plan or be fined. Small businesses in Massachusetts are grumbling about the additional workload caused by complex calculations and paperwork required to comply with state law.

Gary Kolbran, of Wheeler & Taylor Insurance was one of several people interviewed in the Eagle's article. He addresses, among other things, Section 125 plans that allow employees to set aside pretax money from their paychecks to pay for health expenses and insurance.

"All along, I feel like the government has made it extremely complicated," Kolbran said, as with the Section 125 plans, which he called an "elegant way to get part-timers to pay less for their health insurance, but they didn't think about the ramifications on small businesses. I'm sure General Electric has a (human resources) department that can handle this. A small business does not."

Although the state spent money marketing new health plans to people and informing them of the mandate, it did very little outreach to small businesses, leaving that task to trade associations and chambers of commerce.

The transition to the new systems is rocky at times, as unexpected ramifications come to light. One state program that has come to an end under the new reforms is having impact on many small businesses now that they can no longer use it to claim an insurance subsidy both as an owner and an employee of the same business.

In addition the Retailers Association of Massachusetts is pushing for the ability to purchase insurance in bulk for its members, something not currently provided for. Association President John Hurst calls the current situation discriminatory, creating a situation where premiums are far lower for big business than for small ones.

The road to universal health care would seem to be well paved, but you should still keep an eye out for potholes.

SOURCE: "Business owners pay the cost of health care
Paperwork, fees piling up" 12/10/07

photo courtesy of chrisscott, used under this Creative Commons license

Transparency: Health Care Cost and Performance

Today the San Francisco Chronicle brings us an excellent piece co-authored by Bill Novelli (CEO of AARP), James Guest (president and CEO of Consumer's Union and publisher of Consumer Reports) and Peter V. Lee (president and CEO of Pacific Business Group on Health). These three and their respective companies are pushing hard for certain modifications to the final version of California's health care reform legislation.

In short they are demanding that cost and performance data on service providers become publicly accessible.

Many people have fond memories of their grandparents. You probably remember your grandmother taking you shopping as a child at some point. If she was anything like my own grandmother she compared weights and prices and ingredients before deciding on her final purchase. She probably also expounded at length on the virtues of comparison-shopping, and rightly so.

The current state of the health care system here in the United States does not allow that sort of informed choice. This opacity is both counterintuitive and counterproductive. With more data transparency shopping for health care services will come to resemble other types of shopping, you will be able to compare and contrast what you will be receiving for your money.

Many hospitals and private providers are putting up a fight, lobbying for a voluntary program rather than a mandatory one. Novelli, Guest, and Lee take issue with this position stressing that voluntary programs cannot work due to lack of participation by providers.

They demand that certain things be included in the final legislation before it is signed into law:

• Stop compensating for quantity of medical procedures and instead focus on quality of care.


• Preventative care and management of chronic conditions should be encouraged, creating an overall improvement in patient health and a lowering of health care costs.


• Information technology should be used to create access to provider cost and quality data, allowing conservation of both lives and finances

Their summation shares many commonalities with Mr. Halvorson's Eight Developments that Make Health Care Reform Possible. Implementing this sort of transparency can help combat the lack of accountability and inefficiency of our current "non system."

SOURCE: "Health reform must make sure care cost and quality are made public" 12/06/07
photo courtesy of Karmelize, remixed by George Williams and used under this Creative Commons license

LD4: Privacy vs. Policy in Health Care Data Mining

Tarren Bragdon, director of health reform initiatives at the Maine Heritage Policy Center, is in the spotlight today as he shares his opinions of Maine's recently passed law known simply as LD4. What, you may ask, is LD 4? I will allow Mr. Bragdon to explain in his own words (taken from the Bangor Daily News -- typos and all) :

Earlier this year, the Maine Legislature hastily passed LD 4, a law that will go into effect on Jan. 1, 2008. The law restricts access to prescriber-identifiable data, information about which doctors are prescribing what drugs in what amounts. Supporters of this law argue that restricting this prescriber-level data will block pharmaceutical sales representatives from using this data to persuade doctors and others to prescribing more expensive drugs.

However, the reality is that by knowing which physicians are prescribing particular medications is an efficient and confidential means in which to target those doctors treating certain types of individuals. By being able to identify physicians, those with patients who would benefit can be quickly contacted about new medications, the latest treatment research and innovation drug trials. Physicians benefit from such a system because they are provided quick access to the latest technologies and treatment approaches, while patients receive notice of every treatment option available, all in an environment that protects patient confidentiality.

Under LD 4, physicians can no longer be targeted to receive potentially life-saving information.

As with all discussions about data transparency there are a variety of pros and cons to consider, especially in this age of target marketing and identity theft. Mr. Bragdon addresses this by providing an alternative example that has been in place for over a year now, one that allows medical info to be shared among health care professionals, not sales reps.

The Maine law is based on a nearly identical law passed in New Hampshire, which was ruled unconstitutional in April by a U.S. District Court judge. The minor difference in the Maine law is the "opt-out" provision allowing physicians the choice to opt-out of allowing their prescribing data to be accessed.

If physicians want a choice in sharing their prescribing information, a better option is the Physician Data Restriction Program, or PDRP. Sponsored by the American Medical Association since 2006, PDRP offers physicians the option to "opt-out" of having their prescribing data shared with sales reps. Unlike LD 4, the data could still be accessed for the other valuable purposes mentioned previously.

The New England Journal of Medicine recently published a study conducted by the Seattle Children's Hospital Research Institute and the RAND Corp. This study showed that children receive less than half the advised care for conditions covering twelve clinical areas, information that Bragdon uses to shore up his assertion that restriction of information leads to variability of care. Variable care quality has a negative impact on both health care and health care costs.

Bragdon is far from alone. IMS Health Inc., Verispan LLC and Source Healthcare Analytics, sent lawyers to the U.S. District Court in Bangor seeking an injunction blocking LD 4 from taking effect on January 1, 2008. All three companies deal in the collection and analysis of prescriber level data such as that affected by this legislation.

To make things interesting he is answered in another Op-Ed in the same publication. This one by Maine State Senator Lisa Marrache, D-Waterville, a physician who is board certified in family medicine and a member of the Health and Human Services Committee, who refutes Bragdon's points in no uncertain terms.

Bragdon mischaracterizes LD 4 and misunderstands the way safety information is conveyed to prescribers. The Food and Drug Administration already requires drug companies to notify prescribers of untoward side effects, new study precautions and "black box" warnings. To suggest this would not occur if LD 4 goes into effect is preposterous. The law was narrowly crafted to specifically preserve access to prescribing information for safety and health uses. Also, each board of licensure knows who is prescribing, and the federal government has access to the largest database of physicians and other prescribers. Targeting prescribers based solely on what types of medications they prescribe does absolutely nothing to further patient safety.

What about the "opt out," option? Data confidentiality? Enforcement? Sen. Marrache responds:

One reason the Legislature passed LD 4 is that alternatives do not exist. The private, voluntary "opt out" program run by the American Medical Association and touted by Bragdon is close to useless. In the federal courtroom in Bangor last month data mining company executives admitted that even after physicians enroll in the AMA program; their information continues to be sent to the data mining and pharmaceutical companies. Only the drug sales rep and her immediate supervisor don't have access to the data -- but marketing executives may still use the information to create individual prescribe profiles to develop marketing strategies or reward sales reps.

The voluntary program doesn't address the concerns of nonphysician prescribers, including physician's assistants, nurse practitioners or pharmacists. There is no enforcement of violations, and until urged by the New England doctors in a formal resolution, the AMA's own Web site actively discouraged participation by suggesting that physicians opting for confidentiality wouldn't receive free drug samples, often given to patients lacking health insurance. The AMA received 16 percent of its 2005 revenue, $44.5 million, from the sale of its physician Masterfile, which is used by the data mining companies in the creation of their lucrative databases. It is not reasonable to expect the AMA to voluntarily establish and maintain an effective prescriber opt-out system if it makes their Masterfile a less useful tool for pharmaceutical marketing purposes.

One law, two viewpoints, and the uncertain variable of public opinion. This piece of news bears watching as it may well set a precedent for future legislation on the subject of electronic medical records!


SOURCE: "A Bad Pill for Health Care Reform in Maine" 11/30/07
SOURCE: "LD 4, A Step in the Right Direction " 12/04/07
photo courtesy of Night Star Romanus remixed and used under this Creative Commons license

Meeting the Criteria: The American Health Care 'Non-System'

David E. Drake, doctor of osteopathy and clinical professor of psychiatry at Des Moines University, brought us a wonderful opinion piece in the Des Moines Register yesterday. One that highlights the vagaries of a health care system that our own Mr. Halvorson has called "badly flawed, perversely incented, inadequately coordinated, incredibly inconsistent, strategically unfocused, and too often dangerously dysfunctional." His article shares experiences and data he accrued during his attendance at the recent Physicians for a National Health Plan conference.

With some 1,500 private health-care plans with their own confusing array of deductibles, co-pays, and allowed payments, health-care delivery in the United States comes out of a business model that makes money by denying or greatly restricting services even to those who believe they are covered by private insurance.
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Conference speakers pointed out differences in administrative overhead between a system based on a revised Medicare, 2 percent to 3 percent, versus up to 15 percent for private companies, with an additional 15 percent for profits.

He also shares some of the input given by a foreign colleague at the conference, as a contrast with the system here in the United States.

One of the speakers was a Canadian psychiatrist who makes more money than many American psychiatrists, with overhead limited to one to two minutes per day of billing on his part, with all fees billed to one central payer, the government. Speakers were clear that this is not "socialized medicine," but a central payer with physicians still practicing on their own. Socialized medicine would be akin to the Veterans Affairs' system, where the hospital and physicians are employed and run by the government.

The Canadian psychiatrist pointed out that there are regional differences by province, but that he can see a patient as often as he would like, with no co-pays or deductibles. His malpractice is about a third of what I pay, and this tab is picked up by the province as negotiated by physicians and the area health plan. If he believes a person requires inpatient care, he can hospitalize the patient without the need for pre-certification. He and the patient decide how long the patient will stay in the hospital.

This insight into the Canadian way is most interesting, and far less "socialized," than the way it is oft times presented by our political class and the mass media. Perhaps there may be ideas in their approach that we could cherry pick while developing our own?

The good Doctor's points are important ones, and are thrown into sharp relief by the second half of his column, which describes the bureaucratic nightmares awaiting him at his practice once the event was over.

I returned from the conference to see my sole employee, my office manager, overwhelmed by returned claims from multiple insurance companies, denials and a barrage of phone calls to confirm insurance coverage and get approval for outpatient care.

A few days later, I needed to hospitalize a woman who was so overwhelmed with anxiety that she was not able to function - at work or at home. The hospital admission staff told me at the outset that her insurance company would probably deny payment for her stay - that "she didn't meet criteria."

Indeed, initially the first day was denied, only later to be approved, while her three other days were denied even after phone calls from the hospital social worker and me. I was told that since she was neither suicidal nor psychotic, the insurer would not pay for her hospital stay after the first day. The decision was neither about clinical necessity nor good judgment, but about reimbursement and "criteria."

Since 1970 we have increased our number of health care providers by 150 percent, but 2000 percent more administrators. (Yes that does say 2000, it is not a typo.) That statistic alone speaks volumes on the subject, reaffirming once more that what we need is Health Care Reform Now!


SOURCE: "Health 'Non-System' Needs True Reform, Not Band Aids" 12/01/07
photo courtesy of Ack Ook, used and remixed under this Creative Commons license