Welcome to the August Recess Edition of Health Wonk Review

Welcome to the August Recess edition of Health Wonk Review. The Disease Management Care Blog is happy to be your tour guide to this bloggy thinking-persons’ exercise in participatory democracy.

Ha! ‘Recess’ you say? The tens of thousands of DMCB readers know this is only a faux time-out. Citizens, provocateurs, experts, naysayers, legislators, personalities and progressives are all jostling to shape health reform. With all this tumult, there is no way us bloggers aren't going to get even more.... wonky. Indeed, given the number of HWR submissions, the health policy blogs are very engaged. While each posting is individually convincing, this lengthy HWR demonstrates the thorny mix of opinions and options facing our elected representatives.

Is there a middle way of common sense mainstream solutions in all of this? It is up to you, the HWR readers, to decide.

Enter the Health Affairs blog, which is on health reform like hospital administrators are on new MRI machines. There’s a report describing a roundtable discussion about how some showcase communities lowered health care costs (ingredients included enlightened data management and a not-for-profit mission), a Uwe Reinhardt post on using relative value units (RVUs) to transparently level the pricing of health care services across multiple disparate settings and Paul Ginsberg’s preference for a Maryland-style rate setting Board that regulates prices.

Over in the real world, however, a physician office visit may cost a $100. A CAT scan may cost a $1000. Who can blame the physicians for wanting to own the CAT scanner and snagging all $1,100? Well, Tom Emswiler of the New Health Dialog Blog has read the Washington Post story about the allegedly renegade urologists who had the temerity to not read Health Affairs and figured out how to get that $1100 over and over and over again. Tom is not only willing to assign blame but points out there are ways for insurers to collectively fight back, including bundled payments or developing a radiology-specific sustainable growth rate (SGR) formula.

While brawls on divvying up the revenue continue, the Medicaid community is busy divvying up the costs. At the Health Access Blog, Anthony Wright dissects a recent letter from Governor Schwarzenegger addressed to members of Congress about health reform. Go there to get great insight into the tug of war between the States and the Feds over paying for and controlling Medicaid. While the States’ Governors are suffering from sticker shock, Anthony asks if asking States to meet a Medicaid mandate is all that dissimilar from an insurance mandate for individuals. The DMCB thinks this may be one of the few areas where reform doubters would actually agree with Anthony.

Like Bob Vineyard of InsureBlog, who notes the Federal funding for Medicaid has been on chronic ‘life support,’ and that State Medicaid programs have had to resort to onerous methods of funding like putting liens on nursing home resident’s estates. He wonders where any additional money is going to come from, unless the use of liens is expanded whenever any beneficiary uses any Medicaid benefit.

It’s only money though. Yet, the only group working harder than the health insurers to get more of it are the State and Federal governments. Merrill Goozner of GoozNews Blog provides an insightful discussion on the pros and pros of intelligently taxing our way to broad health insurance coverage. He finds lots of money in options such as taxing high end health insurance plans and/or increasing the Medicare payroll tax with a 1% increase and/or taxing sacrosanct ‘non-wage income’ that is disproportionately earned by high-income citizens.

Brady Augustine seconds that latter motion at the refurbished MedicaidFirstAid blog. While he worries about the inverse relationship between overall tax revenue and higher taxes on capital gains, he believes it can be fashioned so that the impact in minimized. In fact, Brady’s got a detailed proposal: a 1.45% percent employee contribution on non-wage income, which would leave the rate of 16.45% still significantly less than the rate that existed during our best two periods of capital gains tax revenue.

Speaking of money, does exempting small businesses, defined as having a payroll of less than $500,000, from an employer mandate makes sense? Simple question and Jason Shafrin of Healthcare Economist has a characteristically simple answer: yes it does. After all, if he had a complicated answer, he’d be an actuary. Jason cuts to the chase by noting that small employers have a higher cost per employee and are at risk, without the exemption, of being at a huge competitive disadvantage versus the big companies. Beware of unintended consequences, however, since a company with a payroll of $499,999.99 or less would have a significant incentive to put an indefinite freeze on hiring, putting the kibosh on the small business engine that accounts for a lot of employment in the United States.

Would small employers and the rest of us be hurt by the monopsony of large regional insurers? The Incidental Economist isn’t so sure about that because there is plenty of literature that also isn’t too sure about this. TIE does a great job of summarizing that literature and examining the underlying issues. He also provocatively suggests that provider consolidation is more of a threat when it comes to the optimal pricing of health care services. Great links.

Louise of the Colorado Health Insurance Insider reminds us that individuals sure are being hurt by not being able to get a tax break when they purchase insurance outside the employer market. She hopes there will be plenty of changes in the coming decade. So does the DMCB.

Naomi Freundlich of Maggie Mahar’s HealthBeatBlog argues that legal (repeat legal, i.e., the kind with green cards) immigrants should be included in any health reform that includes covering the uninsured. It seems Massachusetts’ health reform journey is veering to the right on this issue thanks to overblown anecdotes from penny-wise pound-foolish conservative reactionaries. Naomi reminds them that legal immigrants not only pay their fair share of taxes, they’re a low insurance risk. What’s more, if they use health care services that aren’t covered, we’re all going to end up paying for it anyway. Except for the politics, Ms. Freundlich says this is a no-brainer.

Alas, ‘except for the politics’ sighs the DMCB. On the right, there’s ‘‘JD’s’’ take on a recent contentious town hall on health reform involving HHS Secretary Sebelius and Senator Arlen Specter (D-PA). JD appears to share many a Philadelphian’s skepticism about this health reform thingy. Maybe they’re confused by their Senator’s recent switch to the Democratic Party. Or maybe it’s because London’s Big Ben was switched for Philly’s City Hall. On the left, folks like the Health Plans Plus blog are not confused. The politics are easy. Mix facts. Bake. Serve up single payer system to JD’s Philly curmudgeons and they’ll be sure to change their mind and write to their Congressman.

No wait, maybe not if they watch TV. An ad is being run that features the Canadian woman who claims she would have been dead thanks to a ‘government run’ health care system. You can read all about Ms. Shona Holmes at Sam Solomon’s Canadian Medicine. See if you agree that her story and its use by partisan foes to demonize the Canadian health system may be enough to upend President Obama’s health reform efforts. In the meantime, the DMCB wonders why the Holmes ad includes a CAT scan of the abdomen, unless she was being cared for by American urologists who should read Health Affairs.

Joseph Paduda of Managed Care Matters has the most interesting take on the politics of the anti-reformists. It appears they are well organized and well funded by the usual cast of suspects. That must mean that they are really terrified that health reform could happen this time. Their horror is cause for your celebration if you want to see those health insurers and medical device manufacturers get their comeuppance.

Maybe it isn’t money or being mentioned by the media, reported in journals or included in some politician’s speech. Maybe it’s a matter of local grit, determination and pioneering by locals that have decided enough is enough. You’ll see what Joanne Kenen means by this in her post back at the New Health Dialogue Blog that describes creating a picture of health(y) for the nation’s capital.

But Wright on Health says sorry, it is the money. He has done some nifty analytics using public domain data and found there has been an alarming increase in the percent of funds devoted to lobbying by the usual physician, hospital, pharmaceutical and insurer groups and that there are jumps in the money being thrown about whenever major health care legislation has a chance of passage. What seems to inhibit the lobbying is when Congress and the Administration are tied up in partisan knots. The DMCB wonders if this may be a good reason to look forward to the 2010 elections. Check out Brad Wright’s excellent posting here and encourage him to keep digging into the data.

Or maybe it’s humor we need to get everyone to compromise: Good thing Mad Kane is the blogger, who is for Repubs a sharp flogger, no mercy she gives, with limericks she ribs, opponents are poetry fodder. What’s more, the DMCB is aloof, always wanting to see enough proof.... that it isn’t belief, that we need for relief, or the treasury will certainly go ‘poof!’

But seriously, to make things even more complex, us wonkers are concerned about far more than just revenue, costs, tax policy or politics. We care about other stuff.

Like employers gone bad. Really bad. Case in point is the story of Chong-mun Chae at Lynch Ryan’s Workers Comp Insider. Mr Chae has been convicted of taking double advantage of the asbestos abatement business by using cheap untrained and now poisoned labor and not paying any workers’ compensation insurance. The DMCB wonders once again about the effectiveness of our regulatory bureaucracy.

Like information technology. David Kibbe and Brian Klepper are very excited about the Office of the National Coordinator's Health Information Technology Policy Committee’s recent recommendations on how to certify components of the electronic health record. Not only do David and Brian believe the recommendations are common sensical, but stand in stark contrast to the self-serving features promoted by the old guard legacy EHR vendors. Read it and see if you agree that this latest effort at EHR functionality deserves terms like ‘monumental,’ ‘bold’ and ‘forward thinking.’ You can check it out here in the granddaddy of blogs, The Health Care Blog (THCB).

Like information technology Part 2. Here’s a new concept for you to quote the next time there’s an HIT-related meeting: the “Penguin Problem,” or how the inertia of individuals’ self interests can inhibit a perfectly rational collective action, like diving in after some tasty small fish or adopting electronic health records. Vince Kuraitis of the e-CareManagement Blog is also very optimistic that the Fed’s recent actions on defining the “meaningful use” of EHRs and certification criteria EHRs will finally prompt everyone to jump in. The DMCB is right behind Vince on this one. But, if they’re not jumping in, there is a formula with lots of options for at least getting them engaged in a roll-out, says Elyse who muses about the topic over at Anticlue.

Like information technology Part 3. Think personal health records by definition enable patients to be virtually mobile health care information consumer/managers? Think again, because your personal bank’s willingness to help you bank on-line for free is really a plot to prevent you from transferring your account elsewhere by having to start over again. Ken Terry over at BNET Healthcare points out that employers are wise to this gamesmanship and are working with a few enlightened insurers/health systems to overcome this.

Like the advantages of automation. For example, we can automate toll booths and paying for groceries. Heck, some evil-doers have even figured out how to automate the submission of blog spam to the Health Wonk Review website. Why not automate the dispensing of medication to patients? Less room for error when a machine does it says Carla Corkern of Talyst, who is interviewed by David Williams of the Health Business Blog.

Like the use of social media and healthcare communications. David Harlow of the HealthBlawg provides a detailed list of considerations that need to be addressed by medical organizations that want to jump into this field. In the spirit of our age, go ahead, David says Yes We Can and, what’s more, the lawyers won’t always say no you can't.

And most importantly, by conflicts of interest. It appears even us bloggers can be ensnared by being inattentive to not-for-profit organizations’ corporate sponsors. Blogs are edgy, provocative, trendy and widely read, which is making our ability to drive web traffic attractive prey to marketing firms. Be afraid, says Roy Poses of the Health Care Renewal Blog, be very afraid.

Because if we’re not afraid, we could end up being used like some unbelievably tone deaf physicians. These are highly paid willing participants in the pharmaceutical industry’s questionable marketing campaigns, who have been lambasted in the national press and scrutinized by U.S. Senators. Their response? Form an organization that promotes physician participation in the pharmaceutical industry’s marketing campaigns. You can read about this medical anti-universe here in Tinker Ready’s Boston Health News Blog.

OK. You’ve read all this HWR stuff. You’re smarter for it. Now look at this video and figure out what to do next.