Welcome to the "Tree of Blogs": An Avatar Movie Inspired Health Wonk Review

Welcome to the Health Wonk Review, a hosted compendium of high-quality health policy blog postings with insights you don't typically see anywhere else. And how fitting, given how the January 20 deadline for submissions for inclusion in this HWR also happened to be the one year anniversary of the Obama Presidency.

What a year it's been. Even the most logorrheic bloggers are having trouble finding the superlatives that come close to describing the tumultuous events of the last 365 days. The health reform imbroglios, drama, debates and politics has been much like the 'fix' of internet donations to a member of Congress: hard to fully grasp but immediately addictive.

Even with so much going on, your humble and solicitous host, the Disease Management Care Blog, had little trouble identifying the most important, the major, the most significant event in the last year that could serve as a HWR theme. That's right, it's the Avatar movie inspired HWR.

The Disease Management Care Blog proudly presents The Tree of Blogs*.

Just in case any readers' disdain of popular culture or unwillingness pull away from C-SPAN prevented them from seeing this marvelous cinematic work, the DMCB salutes your discipline and provides this quickie synopsis: a nice and disabled ex-soldier Jake Sully goes to Planet Pandora, which is being strip-mined for highly valuable unobtainium by the greedy human race. Jake's mind is remotely synched with a genetically contrived and partially human avatar that is designed to infiltrate an indigenous race of blue-skinned humanoids called the Na'vi. Don't you know, Jake's central nervous system does not belong to a military dolt: romance with warrior babe named Neytiri and a series of mind-melds with a shimmering glow-in-the-dark 'Tree of Souls' mends Jake's brain of his evil ways.

In this HWR, readers are likewise invited to open their minds and commune with the accumulated wisdom of this interconnected and timeless Tree of Blogs. Mind meld with these important issues that likewise span Pandora and Earth. The voices that speak out of the mists of the blogmos are just as powerful, just as compelling and just as much fun......

Who best fits the role of the downtrodden Na'vi: the underdog Republican-Conservatives or the reform-minded Democrat-Liberals?

While the Republicans may have won the latest round in health care reform, Brad Wright takes them to task for their past willingness to countenance commentary that is emotional, alarmist and baseless. Using contrasting 'word clouds,' he compares two conservative commentators' rhetoric and demonstrates that one shows it is possible to be reasonable. while the other shows how easy it is to be everything that liberals detest. Now that the Republicans seem to be on the ascendancy, they can start by banishing the obstructionist angry 'you lie' style politics and embrace Pandora-like harmony: at least pray over your victims after you kill them.

John Goodman of the National Center for Policy Analysis points out that many of the Democratic health care reform proposals have been curiously devoid of any identification of just 'who' in particular is supposed to transform the disembodied ideas of health reform into specific actions. Like an elementary school teacher, he notes the presence of verbs without subjects not only makes for incomplete sentences, they make for incomplete policy. John's grades this an 'F,' despite Mr. Obama's December 2009 self-grade of a solid B+.

As we know, the majority of Massachusetts' voters would seem to agree with John Goodman's grade. But never mind what all the experts have to say, check out a series of quick interviews of Massachusett's voting citizenry during last Tuesday's special election by Tinker Ready of Boston Health News. The good news is that folks are paying attention and have a grasp of the issues. The bad news for our politicians is that folks are paying attention and have a grasp of the issues. Like the Na'vi Clans, they are assembling for this time of great difficulty and tribulation.....

We know, however, that legislation always includes favoritism for selected constituents. Just who ends up being favored is always interesting. Case in point: Senator Schumer (D-NY) proposed exemption of the religious Amish from the health insurance mandate. John J Leppard IV uses the Senator's own words against him when he examines how Mr. Schumer ironically saluted the Amish's thrifty self-sufficiency as a reason for the exemption, while the Senator was simultaneously proposing to penalize others who might refuse insurance for the same reason. While the DMCB thinks the Amish community has an effective and very informal form of insurance, it also appreciates the political art of making exceptions to every rule.

Is the planet being strip mined of its health dollars?

Jeff Goldsmith, writing in the Health Affairs blog, doesn't think so. Citing the 'inconvenient' statistics of the annual CMS' actuary's report, he describes how overall health care spending has been blunted for several years, thanks to the tapping out of consumer borrowing and the relative lack of any recent 'must-have' big dollar medical technology or pharmaceutical advances. The only entity that's continued to have an out of control 10.4% appetite for health care services is the government, probably thanks to a build up of toxic levels of Medicaidium and entitlementium. And here's an interesting thought: consumers were so battered by out of pocket health care costs that the resulting financial squeeze may have actually helped to fuel the recession. Like Pandora's bio-botanical network, we are all interconnected.....

Even if non-government health care costs may be moderating, that doesn't stop Louise of the Colorado Health Insurance Insider from arguing that objections to a commercial insurance mandate is misguided. After all, banks require their mortgage customers to buy homeowner's insurance and, if a house burns down, it's not up to the rest of us to cover the rebuilding costs. In addition, there are other key policy considerations, including the need to fairly spread risk and mitigate individuals' personal risk of financial ruin. The DMCB gets it, but also worries that the Democrats will conclude that their recent setbacks were the result of poor communication/education on these issues, not poorly constructed policy that failed to pass muster with a skeptical and savvy public.

No argument on the point about mandates from Anthony Wright of the Health Access Blog and, apparently, from Rush Limbaugh. Recall this conservative talk show provocateur was recently hospitalized with chest pains while in Hawaii. After heart disease was ruled out and he was discharged, Mr. Limbaugh had nothing but accolades for the medical treatment he received and held it up as evidence of a health system that really works. Anthony points out that the Hawaiian health care system is operating under an employer mandate to provide health insurance for workers. Alas, the resemblance between Hawaii and Pandora is only superficial: without a mask to shield him from the toxic vapors of government interventionalism, Rush would surely die.

But let us head to the other side of the globe to Connecticut, where that State's Attorney General has filed suit against insurer Health Net. David Harrow of the Health Blawg discusses how the State AGs seem to be more than willing to use their power to enforce the privacy regulations under the "Son of HIPAA" amendments to the HITECH act. Health Net allegedly dawdled in notifying hundreds of thousands of enrollees about a stolen computer containing their personal health care information. Beware, says David, the AGs are prepared to take consumer protection very seriously if insurers fail to be in full compliance with the letter and the spirit of the law. Hm...seems there is even more Pandoran wildlife out there to deal with.

And what's an insurance budget without a pharmacy benefit? Never mind just the blue pills or the red pills, pills of all sizes, shapes and colors, particularly their costs, are examined here by Adam Fein of Drug Channels. This is a multi-hundred billion part of the national health care budget and it's important that we project costs from year to year. Well, according to Adam, CMS isn't doing a very good job of it. The Agency seems to be over estimating the costs year after year, apparently missing the impact of increased generic medication prescribing. Too bad the Administration doesn't appear to be underestimating the size of the Federal deficit.

Employer-sponsored insurance, including the Cadillac Plans: the insurance equivalent of unobtainium?

Feel overwhelmed by economists' jargon and funny mathematical symbols? You can avoid both by looking at Austin Frakt's review of an important analysis of the decision-making that goes into employer sponsored health insurance. There are myriad decision points over the benefit package, type of plan, projected enrollment, the worker/employer allocation of premium payment, the workforce profile, the labor market and the overall business strategy. Oh, and, by the way health care too. And we thought only our President was up to marathon planning sessions.

Joe Paduda at Managed Care Matters understands the ultimate intent of the 'Cadillac' health plan tax: it's supposed to put the brakes on high cost insurance and slow down health care inflation. He points out that if this ultimately goes through, the reality will be far different. Not only will regional cost variation unfairly sweep some high cost plans into the one size fits all tax bracket, it also targets employers that have substituted health insurance benefits for wage increases. He suggests an alternative is to tax plans with an unwarranted cost trend, independent of baseline cost or benefit level. If you think that's too complicated, his rejoinder is Yes We Can.

Merrill Goozner of Gooznews on Health doesn't like the Cadillac tax either. He looks to the future and sees rising insurance premiums resulting in more plans and their enrollees being ensnared by the tax or, worse, employers ratcheting down their costs by skinnying benefits or transferring more costs back to their employees. They could respond by skimping on needed health care. Like buying the blue pill instead of the red pill.

Henry Stern of the Insure Blog also agrees. He has one telling example of a health insurance plan that is up for renewal that would be in the Cadillac Tax bracket. He points out that that's not the result of a richer benefit, but the a) adverse trend of that particular group that is not controllable and therefore unfairly included, and b) the coverage mandates that have been imposed by special interests that are also driving up costs. Cadillac? Hardly. Blasting away at these plans is like attacking the Na'vi Hometree: there are women and children at risk!

Let's not forget that health insurance is not the only dynamic in covering workers. There's also Workman's Compensation Insurance. If you had to guess if younger or older workers are more prone to the kind of work-related injuries that trigger a WC claim, would you guess 'older?' You'd be wrong, because experts like Lynch Ryan of the Worker's Comp Insider continue to remind us that older workers are good WC risks, even if they seem to have longer recovery times. If you want to learn more about this and about the different WC market segments, you should check it out. And remember f you're injured on the job and don't have health or WC insurance, then you might as well pray to the Pandoran god Eywa for guidance. You'll need it.

Avatar characters ride around on the backs of fantastical creatures called Banshees. The health care system rides around on the backs of creatures called Physicians.

The Disease Management Care Blog is all for giving doctors more money in the form of lower medical school tuition, scholarship and load financial support, income supplementation, small business assistance, realistic fee schedules and tax breaks. Since policy makers seem to support tying money to outcomes, Chris Langston of the John A Hartford Foundation suggests loan forgiveness be extended to students that eventually enter a career in geriatrics. A good idea says the DMCB, especially since adoption of that idea by the Administration might further cement its remarkably good relationship with the American Medical Association.

Talking about giving doctors money, how about all that cash for adopting electronic records that meet meaningful use criteria? Resources to help readers better understand this are excellently linked up and summarized by Vince Kuraitis over at e-CareManagement. Shahid Shah steps back and reminds physicians that they should be asking other more fundamental questions about the merits of automation, customer service, other outcomes that really count and the types, formats and accessibility of information that will be required. He offers up a list of shorter term and easier steps that can be implemented by docs before they write an EMR vendor a big check. Elyse Nielsen offers her own thoughts of health system workflow efficiencies at Anticlue. Better hurry up though, Mr. Obama is in a hurry to get this done.

How about doctors spending money? David Williams of the Health Business Blog summarizes an interesting study that reports on a cancer doctor survey about health care costs. The majority are already including cost of chemotherapy in their clinical decision making and would welcome additional information based on comparative effectiveness research. As a cancer patient, he asks, which would you rather have: a coverage or treatment decision based on a hunch or one based on real science? The DMCB has seen oncologists come to the rescue of countless patients. When they walk in the room, it reminds him of Jake riding in on a big orange flying Toruk.

But fear not, my fellow physicians, because Peggy Salvator of the Healthcare Talent Transformation blog recounts a reassuring interview she had with national health information technology coordinator David Blumenthal. The government's enlightened use of goal setting to help you use EHRs is designed to stretch not break you. You may feel the heat like a pulled rubber band, but be of good cheer, when they're done with helping you implement meaningful use, the Planet will be better off for it. So cooperate, OK? If this reminds the DMCB of Pandora character Parker Selfridge, it apologizes.

Jake dreams of being able to walk again, but cannot afford it. Is that the fault of the hospitals' economics, ethics or not using check lists?

The States' tax revenue is pancaking and more persons are out of work. That means a double whammy: less money to support the Medicaid budgets while, at the same time, more persons with low income levels are qualifying for Medicaid. In this post, Mike King looks at how the Georgia Legislature and Governor are thinking about taxing hospitals, especially since the extra money will help the State qualify for additional Federal dollars. The hospitals are unsurprisingly opposed to the idea. The DMCB isn't too sympathetic, since the States want to extend health insurance to more people, which will will only help these institutions' bottom lines. Perhaps one way of dealing with the hospitals that can't make it is creating their own version of cash for clunkers.

Maybe the willingness to tax hospitals could at least indirectly be the result of reports of incredibly unethical and illegal oversight of some of their Boards of Directors? Roy Poses, in this January 15 posting (you need to scroll down or go here and here) describes how bloated compensation packages and self dealing are slowly ruining the public's faith in hospitals' ability to do right. While this may the result of a few bad apples, Dr. Poses points out the crying need for functioning and vigorously enforced ethics policies. Maybe if they wake up and realize how tone deaf they can be, we won't want to tax them like the big banks.

Or maybe folks are fed up with resistance of hospitals to the use of checklists to reduce unnecessary complications. According to Magie Mahar of the Health Beat Blog, failure to do so is contributing to the equivalent of six sold-out 747s crashing every day. Doing the same thing on every patient all the time every time has several things going for it: it's cheap, it works, but most importantly, it's the topic of a book by healthcare golden boy, Atul Gawande.

When the Na'vi refuse to cooperate, it's time to call in the marines. When it comes to a unwieldy health care system, is it time to call in the Feds?

Ken Terry shines a harsh light on the States and kicks it up a notch by asking a fundamental question: do the individual States really have what it takes when it comes coralling health insurers? Can they really run exchanges? Can State Insurance Commissioners really do what is best for health plan enrollees? Is there any entity better situated to streamline this than the Fed's Office of Personnel Management? The answer may ultimately turn out to hinge on how you interpret the Constitutional support for an expanded role for the Federal government.


*You're right, the image doesn't look like it's from Planet Pandora. That's because Planet Pandora doesn't have a Tree of Blogs, silly: that's only present here on Earth. Image from Wikipedia