now, that's parenting

Five year old D. had a friend, N. over to play yesterday evening. For a while, I was alone in the house with them.

They were playing upstairs, when I heard a loud, "Thump!"

Me: "Are you boys OK up there?"

D. and N. (in unison): "Don't come up!"

Me: "If I come up, will I get mad?"

N.: "You'll get mad!"

So, I waited five minutes and then I went upstairs. All evidence of whatever had happened had been cleaned up. The boys were playing quietly.

This is clearly an example of how what I don't know can't hurt me.

Will We Finally Have Health Care Reform This Time?

Will we have a big health care reform bill passed by the Congress and signed by the President in the next year?Readers of this blog know my opinion--show me where the trillion dollars comes from and I will be optimistic.CQ's Drew Armstrong and Alex Wayne have a thorough and detailed feature article on that question in the April 5th CQ weekly, "A Second Onion."Here's a bit of the article and a

The Fat Lady, Attending a House of Worship, Disease Management Engagement Rates and the Little Things That Count

The Fat Lady reminds the Disease Management Care Blog that everyone should regularly attend a house of worship. Aside from matters of faith, it’s a good way to regularly put things into perspective while taking a break from worrying about tomorrow’s meetings and deadlines. More importantly, you’ll gain insights about the human condition that are generally ignored by popular culture. Heavy stuff indeed.

Presidents are a good illustration of this. Both Kennedy and Reagan, for example, reached for inspiration from the shining city upon a hill. Abraham Lincoln famously pointed out a house divided against itself cannot stand. Even President Obama has told us it is time to set aside childish things.

Well, the DMCB isn’t immune either. It reached into the Easter Service grab-bag for two insights about its little corner of healthcare.

First off, purchasers of disease management programs have long gnashed their teeth over low contact and engagement levels of all persons in their eligible populations. In its business dealings, the DMCB has tried to point out that increasing recruitment drives up costs, enrolls progressively more disinterested patients and counter-intuitively reduces the return on investment. Perhaps it should also point out that that it was recognized long ago that a message far more important than A1c levels, asthma medication compliance or blood pressure control has also been stymied by ears that do not hear. 100% of all eligible patients will never cooperate with disease management, engage with their patient-centered-medical-home team, log onto their electronic health record, buy health care insurance, take their medicines or see a physician. Since less than 100% engagement was described in important literature well over 2000 years ago, the population-base care industry should work on describing what engagement rates are possible, not ideal.

Secondly, the Gospel of John has an interesting detail about the Tomb and the Resurrection:

“and a linen, that was about his head, not lying with the linen clothes, but wrapped together in a place by itself.”

The DMCB isn’t too sure about the significance of the folded cloth separate from the rest of the rumpled burial linens. It was told by a Methodist preacher that the ancient carpenters used this to signal that their job was done. Even if that is not true, the Fat Lady still likes the special touch in this behemoth of a population-based (and soul saving) intervention. The lesson here is that the little things nurse coaches do to inspire, nudge and motivate their patients are as important as any exquisitely constructed, decision-supported, evidence-based protocol. While we think about populations and billions of dollars we’re preparing to spend on chronic illness, we need to remember that the small details also count in ways measured and unknowable.

"A Self-Fulfilling Prophesy: The Continuity of Care Record Gains Ground As A Standard"

A Self-Fulfilling Prophesy: The Continuity of Care Record Gains Ground As A Standardby Brian KlepperWe live in a time of such great progress in so many arenas that, too often and without a second thought, we take significant advances for granted. But, now and then, we should catalog the steps forward, and then look backward to appreciate how these steps were made possible. They sprung from grand

The New Cavalcade of Risk is Up!

Are you a fan of Risky Business? So is the Disease Management Care Blog. You'll be an even bigger fan once you check out John Leppard's posting of the best and the brightest writings on the topic over at Healthcare Manumission.

The DMCB couldn't help itself:

"My name is Joel Goodson. I deal in human fulfillment. I grossed over eight thousand dollars in one night. Time of your life, huh kid?"

"You've done a lot of solid work here, but it's just not Ivy League, now is it?"

"Looks like the University of Illinois!"

Will Health Insurers Become 'Too Big To Fail?'

If a federally supported public plan is launched without careful planning, the answer is they could become that way.

Here's why:

We’ve all heard how the life insurers are in trouble. While Prudential’s, The Harford’s and Lincoln’s investments were more conservative and heavily regulated than those in the shadow banking system, the life insurers were not immune to the carnage in their residential and commercial real estate-backed holdings. Undercapitalized, their variable annuities products (which guarantee minimum returns) are now stressing their balance sheets. Seeing a bail out on the horizon, many life insurers bought banks, which made them technically eligible for the Troubled Assets Relief Program (TARP).

On the face of it, TARP isn't a bad idea. Life insurers own a whopping 18% of the corporate bonds that undergirds a big part of the credit markets. If they can’t buy bonds, these markets’ short term prognosis will remain grim.

Which made the Disease Management Care Blog ask: why aren’t health insurers also in trouble? Well, they are. Rising unemployment is leading fewer persons buying employer-based insurance, which, in turn, is resulting in decreased earnings. Furthermore, many of the commercial health insurers are being battered by problems involving their parent company.

Yet, despite the AM Best downgrades, they’re holding their own. Health insurers are aggressively fighting back by cutting their workforces and reducing their budgets. The DMCB wonders if they were aided by being less inclined to seek big returns by investing in real estate. It could also be argued their bailout has partially arrived in the form of COBRA subsidies. What’s more, the prospect of the Feds mandating coverage for all with means tested subsidies should help. It looks like the insurers are going to weather this storm intact.

But the DMCB thinks there may be a bigger reason for the health insurers’ relative well being: they’re aggressively regulated by Departments of Insurance at the State level. This has functionally forced health insurers to uncouple their business into regional entities with separate P&L statements, separate ‘Yellow Books’ and separate regulations. This is not only true for many of the 'Blues' and other not-for-profit insurers, but even the giants Aetna and Cigna are made up of regional subsidiaries defined largely State by State with oversight by 50 different Insurance Commissioners. While it’s true that all insurers are regulated at the State level, the DMCB thinks health insurers receive more than their fair share of scrutiny. The result has been a crazy quilt complexity that is further scrambled by the different features of the large group, small group and individual markets. No wonder that relief from State regulation has been sought for years. And no wonder that the economic contagion couldn't spread through the health insurers as easily.

In light of this, what are the implications of healthcare reform? As previously discussed in a prior post, the DMCB believes community rating, guaranteed issue and having to compete against a public plan will increase health insurer mergers and acquisitions. As a result, small insurers will evaporate and the remaining health insurers will get even bigger, arguing they need the economies of scale and access to capital that comes with size. If healthcare reform doesn’t include 'single standard' Federal regulations, the DMCB expects the insurers (the ones that are left standing) to seek them, which will in turn allow them to centralize their operations outside of State oversight.

And once that happens, they’ll be too big to fail.

Which is why the DMCB is still a big fan of Nassim Taleb, the author of the highly readable The Black Swan, who recently penned this interesting editorial in the Financial Times. His ten recommendations for ‘Capitalism 2.0’ deserve consideration while policy makers and regulators struggle to minimize the future risk of rare catastrophic financial upheavals. They are listed below, followed by the implications for health insurance reform from your trusty DMCB:

Nothing should become too big to fail – The last thing we need is one or more AIG-like health insurance entities with a critical mass of beneficiaries and providers vulnerable to unpaid bills.

No socialization of losses and privatization of gains – It’s not unusual for insurers to contribute to State-regulated ‘insurance for insurers’ risk pools. In light of recent events, do we know if they are adequate? Who will be responsible for this once health insurance goes truly national?

It is foolish to trust the very experts that got us into this mess – Hear hear! Says the DMCB; health insurance executives should know that failure to fulfill their fiduciary responsibility means they will be banished from the business for life. Will Timothy Geithners of Washington DC really be interested in protecting us from a future health care insurance 'Black Swan?' Do they even know how?

Do not let bonuses hide hidden risks and tie them to downside risk – While health insurers have an underwriting cycle with good and bad years, it’s not just revenue. It’s those ratios on the balance sheets that denote capital adquacy and clinical quality in their dashboards. Bonuses need to be aligned with what is important.

Keep it simple – If readers of this blog cannot understand the fundamentals of their health insurance plan, something is wrong. Ditto legislators, policy makers, regulators and community-based watch dogs. Ditto when the insurers go national.

Ban complex financial products – The DMCB thinks the health insurers’ balance sheets were relatively untouched by this pollution. If that’s not the case, it needs to be fixed and kept that way.

It is not the role of government to restore confidence – It is the role of health insurers to maintain confidence now and in the future.

Leverage is the problem, not the solution. Health insurers are just as vulnerable to the temptation to assume debt in their operations and acquisitions. Regulators at the State or Federal level will need to maintain their vigilance and be given the adequate staff and resources to do so.

Definancialize economic well being – The integrity of a health insurance policy needs to depend less on interest income and more on old fashioned risk pooling.

Blow it up and start over again with Capitalism 2.0 – And don’t spare the health insurers.

++++++++++++

Will you be going to the World Health Care Congress? The DMCB agrees this is one of the premier meetings on health care reform and is very much looking forward to what everyone has to say. If you can't make it, think about that nifty video portal. And, whether you go or not, check in with the DMCB and at the WHCC blog for exclusive updates.

See you there.

random: rubble, reading, rabbit, reunion.

1. The long week end looms and it promises to be a busy one around here.

We are hosting a secular Passover seder for 22 people. At the moment, you can't actually see the top of the dining room table around which most of us will be sitting. We have a ways to go before we are ready. Denial is a wonderful coping mechanism.

My sister and I both married Jewish men, despite being raised in the Catholic Church. My spouse and his brothers all married shiksas (we are reclaiming the derogatory term). We do Passover and Easter (otherwise known as "chocolate rabbit day" or "the one day every year that my kids eat chocolate for breakfast").

On Sunday, the Easter Bunny will be setting up the egg hunt at my spouse's brother and sister in law's house. I'm pretty sure the Bunny will remember to drop off some loot here, too.

2. It seems I have a lot of reading to do.

I have book reviews I need to write for Library Thing and for the Harper Collins First Look Program.

I also have stacks of unread books.

But every time I see or read about a book that might be interesting, I order it from the library. I usually do a pretty good job of making sure that most of these requests are "inactive" so that everything doesn't come in at once.

I forgot to check for a few days (this is really unlike me, I tend to be obsessive about anything involving lists). I now have 24 books ready for pick up and another 45 in transit. I also have 13 already checked out. I think I might be in trouble.

3. Yikes!

I am stressing myself out writing this post. Really, library books, unfinished knitting projects and the novel outline I haven't touched since New Year's Eve shouldn't be stressing me out.

4. After my last post, my mom and my sister have both told me that I am motivating them to re-commit to exercise.

I think that's so cool.

5. One of my Ottawa friends is going to deliver a copy of my book to a friend in Uruguay.

How cool is that? CR has been a friend for many years and we worked together for a while (in the possibly carcinogenic building). CG was my college room-mate 24 years ago and we have recently re-connected.

CR and CG are going to hook up and take a picture together. I cannot tell you how thrilled I am about this.

Going to go walk the dogs, drop off the book and, if there's time start to clean up the house.

Wish me luck.

And have a great week end.