The Baucus Blueprint for a Call to Action for Healthcare Reform, Part 1

Readers of the Disease Management Care Blog will probably want to pay attention to that ‘Sleeper of the Senate,’ Max Baucus (D – Montana), Chair of the all powerful U.S. Senate Finance Committee. He’s released his own Call to Action, a.k.a a ‘blueprint for healthcare reform’ ahead of any proposals by President-Elect Obama or Reformer-Select Ted Kennedy (D - Mass.). It’s not a legislative proposal but a flexible outline backed by a prodigious number of peer-review references that is intended to guide an ‘investment’ intended to improve healthcare quality, reduce costs and put the system on a ‘more sustainable path.’ There won't be any reform without his input, so when he speaks, Capital Hill listens. So should you.

It promotes employer-based insurance, relies on guaranteed issue of ‘actuarially equivalent’ plans, offers up a publicly financed Federal Insurer, uses a Massachusetts style Health Insurance Exchange (HIE) to match insureds with insurers, temporarily lowers the Medicare eligibility age to 55 years (if you can afford the premium that is designed to be cost neutral until the HIE kicks in) and lowers the income eligibility of generic Medicaid to 100% of the Federal Policy Level. It envisions a new governmental oversight entity called the ‘Independent Health Coverage Council' that will be made up of individuals nominated by the President and confirmed by the Senate ’

The DMCB offers up these observations about the insurance implications of the Baucus Blueprint (BB).

Think of this as play or pay with a tax credit sweetener. The theory is that making all persons buy-in will expand the risk pool. By forcing more low-risk players into the DMCB’s ‘risk transfer arena,’ the average price of transferring risk will drop. That should theoretically should decrease the cost of health insurance but the DMCB points out a) that has yet to happen in play or pay Massachusetts and b) the reason insurance is so expensive is because healthcare is expensive.

A Federal Insurer could be either/both a) an insurer of last resort (designed to avoid 'crowd out' by being a little bit more expensive than the other carriers but, in the end, it will cover you) or b) a competitor that forces the other plans to offer lower prices so that they avoid losing the member months of revenue. The BB appears to favor the latter but uses the former.

The BB's guranteed issue and uniform benefit would force all insurers to compete on price. While unstated, the DMCB suspects that this will increase the insurers' efforts to squeeze savings from the health care system; how well this will succeed remains to be seen. There are oodles of other proposals pertaining to quality - more on that later.

To give you an idea of the scope of the Independent Health Coverage Council, it would define what comprises ‘insurance’ and just what ‘affordability’ is. Big problems command big solutions, but that is an astonishing amount of power. This may be a key stumbling block in the filibuster prone Senate.

The Blues have been cautiously not unsupportive of this and AHIP is mulling this over. The DMCB suspects health insurers are grappling with the prospect of a) more premium revenue thanks to more persons being signed up and b) many smaller regional plans going out of business because they can't afford guaranteed issue. Health insurers will ultimately have to decide if resembling regulated utilities is all that bad.

In its next post, the DMCB will discuss the BB's chronic care proposals and some of the implications for disease management. Hint: things are hanging by a thread and the business model needs to evolve.

The Baucus Health Plan Proposal--Evidence There Is No Consensus on the Key Health Reform Issues

Max Baucus will be a key player in the health care debate the next two years. As chairman of the Senate Finance Committee he has jurisdiction on many of the key issues including Medicare and provider payment reform.He is also a leader in the true bipartisan spirit--something crucial to actually getting reform done.Yesterday, he released a 98-page white paper, "Call to Action--Health Reform 2009."

Latest Health Wonk Review is Up!

The easy part is over. The votes have been cast. The election is over. The polling is gone. Now, policy has to replace personalities, data needs to supplant rhetoric and compromise needs to prevail over politics. YOUR job is to get informed about our health care mess and what we can do to fix it.

But do not fret! Louise of the Colorado Health Insurance Insider Blog has assembled a wonkish series of posts that you can use to be a better citizen and a resource for your elected representatives. You'll be really really smart too.

Start your journey to maximum health policy braininess here!

the man in the boy

I see the future.

photo: G. Nera

And it scares me.

Hallowe'en 2008. Wolverine (think Hugh Jackman in the first X-Men movie).

An Example of How the Mainstream Media Fails When It Comes to Health Care Policy

The Disease Management Care Blog has generally shied away from commenting on the mainstream news' peculiar ability to misinform the public thanks to considerable medical illiteracy, shrilly sensationalism, political bias and a remarkably lazy ineptitude. But it cannot resist after it made a big mistake and watched the November 12 ABC’s ‘World News with Charles Gibson’ tonight. Below is slightly edited blue text taken from a segment morosely titled how “Americans Cut Back on Medical Care.” Commentary from the DMCB is in black.

'Bette Corbett says it seems that every day, she gets a new medical bill for the chemotherapy treatment for ovarian cancer…. After paying for the basics, such as food and gas, the 52-year-old who lives outside Boston says she cannot seem to make ends meet. Her doctors recommend she get a CT scan to see whether her cancer is progressing, but Corbett has decided not to, at least for now….'

It is not uncommon for the media to open with a compelling anecdote to set the stage. In this instance, a heart-breaking yet highly lethal (45% survival at 5 years) and relatively uncommon (8.5 to 16 per 100,000) condition was chosen, probably less on the merits of any generalizable lessons and more on its ability grab the viewer’s attention. From the synopsis above, it sounds like the patient has gone through a first round of treatment. Accordingly, the purpose of a CT scan is to monitor for a relapse. Unfortunately for persons with relapse, cure is generally not possible. Lead time bias and the comfort of knowing what's going on aside, does forgoing a CT scan make that much of a difference, really? It does for Bette, but first dollar coverage of all high dollar imaging with questionable value makes for lousy policy.

'Even though Corbett has medical coverage through her job as a customer service agent, she says she cannot afford the rising deductibles and co-pays, and is close to meeting the cap on her insurance.'

Bette’s employer chose an insurance policy that cannot afford to fully cover the rising cost of health care services. Co-pays and deductables are a time honored approach to keeping the monthly premium down, which is not only linked to the ability of companies to maintain higher levels of employment, it is what Bette’s fellow employees would probably prefer. There are two lessons here: 1) when it comes to insurance, you get what you pay for and 2) Massachusetts’ (where Bette lives) universal coverage falls short of assuring access to care. Now onto to the bigger picture....

'According to a recent survey by the Kaiser Family Foundation, nearly half of Americans report that someone in their household skipped necessary health care in the past year because of the cost. Just over one-third said they've put off or postponed needed care, and three out of 10 said they've skipped a recommended test or treatment…. Some doctors worry that the economic crunch will cause controllable conditions to escalate into major medical problems.'

You can find the report here. It’s based on a nationally representative same of over 1200 adults. Yet, the real question is what is the prevalence of skipping and postponing care among persons with employer-based insurance? As for 'the doctors,' research has demonstrated that many, not 'some,' doctors don’t worry at all about the escalation of controllable conditions. Their inertia, not an 'economic crunch,' is the bigger problem.

'"What you think is a simple thing you can skip, becomes a disaster, a medical disaster, and the difference between life and death," said Dr. Richard Penson, the clinical director of medical gynecologic oncology at Massachusetts General Hospital.'

Medical disaster? The difference between life and death? At this point, the DMCB lost track of what simple test we were talking about. One thing is pretty clear from the peer review literature, however. While doctors disappoint when it comes to preventive medical management, we love to test. Much of the literature is devoted to helping physicians intelligently skip the testing that is one ingredient in making health care the disaster, and the difference between solvency and bankruptcy.

'Jean Mitchell, who researches health care at Georgetown University's Public Policy Institute, thinks the problem is not just people who have lost their jobs and, therefore, cannot afford treatment, but also people who are still employed and have to pay high co-pays on their insurance plans. "Even for people who have insurance, they are faced with paying an increasing share of the health insurance bill out of pocket, which makes them question whether they really need each type of health care service," said Mitchell.'

That is one credible perspective, but at the same time, Aetna has been selling a consumer directed health plan with an increased share of the bill that they say has not prompted persons with diabetes to skip services. Maybe they’re misstating the numbers outside of a peer review setting. A better analysis is this one, which showed an approximate 4% increase in the number of consumers that were forgoing care. As money gets tighter, that number will go up, but this is hardly the kind of widespread epidemic of substandard care implied in this news segment.

'On top of the cost of a doctor's visit is the expensive trip to the pharmacy. Patients taking multiple medications are plagued by higher costs.'

Whoa! Talk about a two-sentence drive by shooting. Nothing like spreading the blame to include that favorite whipping boy, big bad pharma. By the way, most health plans fund medications outside of the medical benefit, but that wasn't mentioned. The DMCB is surprised ABC didn't toss in the health consequences of global warming.

'More Americans find themselves forced to choose between short-term survival and long-term health. For Corbett, whose bills are mounting, postponing her CT scan is an unforeseen repercussion of the crumbling economy.'

Even before this news segment aired, it was pretty clear that more Americans are confronting the rising costs of health care and are being forced to make tough decisions. Now more than ever, viewers need to know just how which Americans, to what degree and in what sectors of health care. Based on the half truths and framing of this faux analysis, millions of American citizens have made no progress in understanding what we're up against. No wonder evening news viewership is declining.

Coda: Could it have gotten any worse you ask? Later on in the same broadcast, viewers were informed by ABC news about that public health menace called shopping carts.

very reassuring

Me (after a harrowing conversation among a group of my friends) to my dear spouse: "Are you leading a double life?"

Long-suffering spouse (who has been single-parenting lots of late): "Are you kidding? My first life is out of control. Why would I want a second one?"

Good enough for me.

An Outstanding Review Appears in JAMA about Population Based Outcomes Studies

For your consideration. Canucks Christopher Booth and William Mackillop of the Queen's University in Ontario have an on-spot article in the latest issue of JAMA. After citing three telling examples of the contrast between randomized clinical trials (RCTs) and population based outcomes studies (PBOSs), the authors provide some needed guidance.

The three examples are 1) an exquisitely performed New England Journal study that demonstrated spironolactone (a special type of diuretic) caused persons with chronic heart failure to live longer and stay out of the hospital more often. Use of this drug increased (including among the DMCB's patients) until a follow-up PBOS showed no change in inpatient stays for CHF but an alarming increase in the incidence of a life-threatening spironolactone side effect: high blood potassium levels; 2) after the publication of several studies, the National Cancer Institute announced chemotherapy should be used in persons with cancer of the cervix. A follow-up PBOS confirmed that women with this kind of cancer were indeed living longer; 3) lacking an ability to perform a RCT, a PBOS pre-post study was used to assess the relationship of inpatient versus outpatient care for persons with mini-strokes. Inpatient care was associated with a better outcome, leading to this approach becoming the standard of care.

The authors correctly caution that the entire population has to be included (to avoid referral bias, ie the selection of persons most likely to benefit), other events that may influence events have to be accounted for, sorting patients by condition not treatment is necessary and, last but not least, a comprehensive registry is vital. There is also a dig at the real purpose here: not citations or publications (or grants that fund Departments, or attending scientific meetings filled with other scientists, or getting rank and tenure), but real meaningful improvements in patient and society well being.

The authors are not trashing RCTs, merely putting them into perspective. They have their place. However, they show PBOSs can add additional insights and can help guide therapies when RCTs are not possible or when RCTs fail to provide the whole answer.

Implications for the disease management community? For starters, we should put this reference in all those citations at the end of our glossy marketing literature. But more importantly, we should be challenging ourselves as well as government and commercial payers to use our/their population-based data bases to invest in and perform PBOSs; if investing in them is not possible (though Kaiser tells us otherwise), making them publically available on-line is another option. In addition, there is a growing science around PBOSs. It's time to get exquisitly familiar with the methodologies and install in it our DNA. Last but not least, we need to caution our policy makers about the merits and risks of having an information monopoly centered in a national center for comparative effectiveness that favors RCTs.

Unfortunately, access to the full manuscript and its bibliography is available by subscription only. It's still worth trying to get a copy.

Booth CM, MacKillop WJ: Translating new medical therapies into societal benefit. The role of population-base outcome studies. JAMA 2008; 300(18): 2177-2179