The recent CONCORD report on cancer survival rates has been used by some on the right to support their contention that the US health care system is superior; according to Catron, the “much-maligned U.S. health care system is the best in the world.” Catron and his fellow travelers’ use of the researchers’ findings has been, to be kind, selective at best.
The study looked at populations around the world, including 16 US states and a half-dozen metropolitan areas that represented 42% of the US population. (Not all state data was available due to collection issues and standards). Four types of cancer, including breast (women), colon, rectum and prostate, which comprise a majority of all newly diagnosed cancers in adults were examined.
From this, Catron concluded:
“Nowhere is this [the superiority of the US health care system] more obvious than in the area of cancer treatment. John Goodman reports on another study published in Lancet Oncology showing that the U.S. has the best cancer survival rates:
[this is a quote from Goodman, not from the Lancet] “A new study of cancer survival on five continents lays to rest the theory that Americans fare poorly compared to other developed countries … in almost every category Americans survive cancer at higher rates than patients in other developed countries.”
Here’s a chart showing U.S. survival rates for breast and prostate cancer compared to the survival rates of four countries whose health care systems are often touted as superior to ours”
Here are a few of the problems with Catron’s argument.

• Catron used two types of cancer, not the four that were studied. And the two he used were (surprise!) the ones that favored the US. Rectal and colon cancer survival rates were statistically similar in the U.S., Japan, Canada, France, the Netherlands, Sweden, and Australia
• There’s no doubt the US survival rate for one of his examples – prostate cancer – is very high. There’s also no doubt that this cancer is way over-hyped in the US, with much more screening and testing, lots of which identifies cases that are unlikely to be fatal. Prostate cancer is quite common among older men. It usually grows very slowly, so slowly that most of us end up dying from something else. So we’re paying way more for screening that is marginally useful from a population perspective.
• The incidence of diagnosed prostate cancer in the US is much higher than in other countries
• Catron may have meant to say that the US health care system is much better for white folks. In the US, there’s a wide disparity in survival rates between blacks and whites. For breast cancer, survival for white women in the USA (84.7%) was 14% higher than for black women (70.9%). For colorectal cancer, white patients in the US had survival rates 10% higher than for black patients (60% compared with 50%). For prostate cancer, However, there was a 7% difference in survival between black and white men (92% compared with 85.8%).
• The US stats covered less than half of the population; we don’t know if survival rates in the other 58% of the population are better/worse/the same

The leaps of logic in Catron’s argument would do credit to gymnasts with Olympian aspirations. First that the data is complete (it is not); second that survival rates for two types of cancer is a fair evaluative basis (what about other maladies?): and third that the US has a better health care system because of breast and prostate cancer survival rates.
The logical errors in Catron’s analysis, combined with his faulty arguments, would be laughable if they weren’t representative of how some actually ‘think’. Their approach to any issue is to try to scare the bejesus out of folks, ignoring data and evidence contrary to their opinions. This does them no credit, and over the long term likely undermines their attempt to influence the dialogue on health system reform.
Looking at data from the Commonwealth Fund, and employing Catron’s logic (better survival rates = better health care systems), we find that the 5 year survival rate for kidney transplant patients was 94% in Canada, 86% in the UK, and 83% in the US in 2001. Does this mean that the Canadian system is better than the US system? Of course not – and I’d bet that Catron and his ilk would be quick to point out the problems inherent in drawing such a conclusion.
What does this mean for you?
If you torture numbers long enough, they’ll say anything you want them to. Catron’s misuse of the CONCORD statistics is Exhibit One in the case against this horrifying practice.

There are those on both sides of the political debate (and some who fancy themselves in the middle) who use anecdotes, scary stories, hyperbole and highly elastic versions of ‘true’ stories to support their solutions to our present health care insurance disaster.
While both sides are guilty, I’d have to say the free marketers look to be ‘guiltier’. Case in point – I’m on the distribution list (at least at the time of this writing) for a few PR firms that have been hired by conservative types to get bloggers to espouse the libertarian, it-ain’t-broke-that-bad-so-don’t-fix-it perspective on health care reform. And they tend to try to scare the crap out of everyone with horror stories of waiting lists in Canada, patients expiring in the UK on transplant lists, and folks with furrin accents invading American hospitals as they try to get kidneys or MRIs or gall bladder surgery without waiting till three years after they’re dead. And these are the reputable folks – there’s also a lot of misinformation circulating in the webosphere about bad Canadian health care.
Not to say this doesn’t happen – there’s no perfect health care delivery/reimbursement system anywhere on earth (although the VA looked closer than most before it was underfunded).
Are there waiting lists in Canada? Yep – but they’re not intolerably long. Are there waiting lists in the US? Yep. Which one is shorter? Depends. Do you have insurance? If you aren’t insured and live in the US, the wait is really really long. If you are a workers comp patient in Massachusetts and need a neurosurgeon, the wait is really really long (the fee schedule is so low very few docs will take WC patients).
And let us not forget that American health care system has a pretty poor reputation for delivering consistently good care…
Ignoring the politically-biased reports on waiting lists, it is likely that Americans don’t have to wait as long as Canadians for some specialty care, and some Canadians may actually not get certain services. For that rapid access, Americans pay almomst twice as much.
You can get it cheap, fast, or good – pick one. We Americans have picked fast, ignored good, and certainly ignored cheap. The Canadians picked cheap, are at least as good, and have accepted slow.
Before you vote, consider what you could do with $750 billion a year in the US – because that’s how much we’d save if our costs mirrored our friends to the north.

Two days after going down in defeat, overwhelmed by the physician lobby and AARP, health plans received another shot into the bow.
Rep Henry Waxman announced his intention to schedule Congressional hearings on insurance companies practices in the individual insurance market. What may have gotten Waxman’s attention was the ongoing fiasco in California, where two major health plans joined three others settling claims that they illegally canceled members’ policies.
The Congressional inquiry comes on the heels of multiple lawsuits filed in California against multiple health plans claiming various damages due to policy cancellation. Insurers have described some as ‘political grandstanding’ and ‘totally without merit’. Nonetheless, they’ve also paid fines and agreed to corrective action.
Suits have also been filed and settlements awarded in Arizona,
Is John McCain paying attention? Remember McCain’s reform ‘plan’ relies on the individual insurance market, a ‘market’ that has once again proven it is incapable of acting within the law. McCain seeks to end employer based insurance, replacing it with individual coverage purchased on the open market. The companies who would sell that insurance are the same ones now paying fines for illegally cancelling policies and denying claims.
Let us not forget that McCain’s ‘free market’ is built on insurance companies seeking to make money – and the way they do that is by selling insurance to folks who don’t need it. Those individuals who really need coverage for their current health conditions cannot get that coverage in the vast majority of states, as the insurance company is allowed to specifically exclude certain conditions and/or to charge significantly higher premiums. In fact, there are only five states that specifically require insurance companies to sell policies to everyone regardless of medical condition. (Maine, Massachusetts, New Jersey, New York and Vermont) If you don’t live in the northeast, and if you have any pre-existing condition (and who doesn’t?), you’re out of luck.
Of course, health plans have a solution to this – they will cover a few more folks with pre-ex conditions, as long as the states agree to cover anyone with more serious problems. Now that’s free market business at its best – guaranteeing private companies will take the good risks, and dumping the rest on the taxpayer. The plan, put together after “tireless efforts of the senior leadership of our industry” and seven months of hard work by AHIP’s board would require state high-risk pools to take on anyone who may incur medical costs more than twice the state average, while requiring insurers to cover the rest.
If there’s a clearer statement of the industry’s lack of confidence in its ability to manage health care, I haven’t seen it.
AHIP’s plan crystalizes the problem – (most) health plans long ago gave up any pretense that they would or could actually manage care.
AHIP should change its name from America’s Health Insurance Plans to the ARSC – America’s Risk Selection Companies.
If McCain has a solution to this, he hasn’t published it yet.
thanks to California HealthLine for the inspiration; for an excellent review of the individual market see Julie Appleby’s piece in USAToday.

It’s over, done, finished. For a few months, anyway. With the overwhelming Congressional vote to override Pres Bush’s veto of the Medicare bill (keeping physician reimbursement levels and cutting subsidies for health plans’ Medicare Advantage and Private Fee For Service), the pols can now move on to other issues.
But while they’re working on oil drilling and war funding and education and trade, the ‘solution’ will merely serve to kick the problem further down the road. And when next we round the corner, we’ll find that the ball has gotten much heavier (docs are scheduled for a 20%+ cut. We’ll also find a rejuvenated physician lobby, one with a renewed strength and sophistication, marked by the ‘partnership’ with AARP.
The Senate vote was an even louder repudiation of Bush’s position than the original vote, with four more GOP Senators joining all their Democratic colleagues and seventeen other Republicans.
Twenty-one Republicans voted to cut health plan subsidies and restore physician reimbursement. Twenty-one.
In the House, 153 Republicans (24 more than voted ‘aye’ originally’) joined the 230 Democrats to overturn the veto.
Some (including Shadowfax) have said physicians don’t have pull in Washington. If you don’t believe in the power of the AMA now, I respectfully suggest you go back, do the math, and ask the GOP members of the House and Senate what made them change their votes.
The next time Congress tackles Medicare, you can be sure health plans’ influence on Capitol Hill will have waned; no, diminished; no, disappeared; no, that’s not quite right either. Suffice it to say that health plans lost this round, and lost it badly. And they have no one to blame but themselves. Appalled by stories of health plans canceling policies, wildly overpaying executives, and cutting back on coverage and physician compensation, Congresspeople found it pretty easy to take a few billion out of health plans and give it to docs.
As Bob Laszewski said when asked about health plans, “Now they have zero political capital, and they’re just going to have it done to them next year.”
When it will hurt a lot more. By digging in their heels, health plans likely lost their last best chance to play a dominant role in future health care reform negotiations. Instead, they will likely find themselves with a seat or two at the table, but those seats will be at the far end, away from the powerful and influential.

Several sources indicate Pres Bush is going to veto the Medicare bill (that rescinded physician reimbursement cuts and phased out Medicare Advantage subsidies). The veto may happen today.
Oops, he just did.
The Senate and House are likely to vote to override the veto pretty quickly – perhaps within a day or so. If the veto is overridden, it will be the first time a Bush veto went down to defeat.
A post on the Wall Street Journal’s blog is notable not for the content (which appears accurate and timely nonethless) but rather for the tone and anger of the commenters. Remember folks, this is the WSJ, perhaps one of the most conservative publications in the country – yet the WSJ’s readers are beyond angry with Bush and his pending veto. Think livid, furious, outraged, hyperventilating mad. This isn’t exactly good news for McCain, who now will have yet another opportunity to either avoid voting on this (as he has to date) or will have to actually take a position.
If the veto is not overridden, it is going to be a holy mess out there in IT/reimbursement/physician contracting/patient access/state regulatory land.
Here are a few potential problems.
1. States that base their WC fee schedules on Medicaid will have to decide whether they are going to follow suit; and for those that are directly tied to Medicare, expect big noise from the occ med, ortho, and neuro physician communities.
2. CMS is going to start processing bills today with the 10.6% cut – and docs are going to start dropping out of Medicare at a rather rapid rate.
3. Republican legislators are going to be mincemeat during the August recess, which will be even uglier than their ‘holiday’ on July 4.

Last week the National Coalition on Benefits went public with their position on health reform – they don’t want any reduction in the role of employers. The NCB’s position was laid out in a letter to Sens. Ron Wyden (D OR) and Bob Bennett (R UT) opposing the Healthy Americans Act. The big issue for NCB appears to be the HAA’s focus on providing benefits through state organizations, thereby eliminating employers’ ability to offer consistent plans across multiple states.
I don’t get it. Or maybe I do, and it smells like good ol’ special interest self preservation.
According to their website, the NCB represents employers, health plans, and trade associations that provide benefits under ERISA (Federal law that regulates big employer benefit plans, exempting them from state control). Members like the current employer-based system; their position is that “any change must not erode those parts of the health care system that are working…”
The NCB’s letter goes on to claim “The federal ERISA framework also makes it possible for employers to drive value-based strategies that improve the entire health care system by allowing employers to apply leading edge, innovative practices on a consistent, nationwide basis.”
That’s a puzzler. If the current employer-based system is working so well, why

• have premiums gone up 87% since 2000 while the CPI is only up 17%?
• are 10 million of the uninsured working full time at large employers (>1000 workers)?
• did Safeway and Wal-Mart endorse Wyden’s Healthy Americans Act?
• have insurance costs as a percentage of payroll gone from 8.2% to 11% in six years?
• are 30 million uninsured Americans in families where the head of the household is working full time?

According to a source in Sen Wyden’s office, “what the National Coalition on Benefits is saying isn’t the attitude of all their members, even of some listed in that letter. In fact, the NCB had a conference call [last] week with some of the members listed on the letter who were unhappy because they didn’t agree with it.”
Turns out the letter from NCB only reflects the opinions of the dozen members of the steering committee which is comprised of equal numbers of trade associations and employers (e.g. ATT, GM, UPS, Verizon).
The staffer went on to note that “news reports said Boeing was severely disadvantaged in competing with Airbus because of the costs they have to bear for their employees’ health care costs that Airbus doesn’t have to pay because their employees’ health care is paid for by the government. Employers could be relieved of that competitive burden under the HAA.”
Wyden himself responded rather acerbically to the NCB (a change from his usual low-key, laid-back-Oregonian style), saying “We may be talking about the coalition of the un-willing. We have talked to several alleged coalition members — like NIKE, AHIP, Wal-Mart and Johnson and Johnson — and they all say that the letter does not represent their views on the Healthy Americans Act. As for their message, their defense of the employer-based health system sounds eerily similar to the Titanic’s deck crew hyping the merits of a sinking ship.
Whoever wrote this letter can’t guarantee a single American that their employer-provided benefits won’t be taken away. But of course, that’s not their job. Their job is to protect tax preferences for the status quo.”
The Senator has a point. The tax benefits of the employer-based system are well-documented and extensive, amounting to about $200 billion annually for employers. Health benefits save employers and employees taxes as they are paid for with ‘pre-tax’ dollars – dollars that aren’t counted as income for tax purposes. If employer sponsorship of health benefits went away, the assumption is the cash employers spend on benefits would instead be paid as wages (and therefore subject to taxation) or (under the HAA) paid into the state agencies as the employers’ contribution for their workers’ health benefits. Of note, monies paid to these agencies would still be tax-deductible.
Provisions in HAA allow for a transition from the current system over a two year period. Employers would increase their workers’ wages by the amount they had been spending on health benefits. After that two year period was up, employers wouldn’t have to pay employees the added wages, but instead contribute to the state agencies running the benefits purchasing groups. Here’s what’s puzzling about the NCB’s position; the amount employers would have to contribute is about 10% of the total cost of health benefits for their employees – a much lower percentage than they are now paying.
Seems like a pretty good deal for employers.
According to the Lewin Group’s assessment, “Private employer health spending under the HAA is reduced under the HAA by $309.8 billion, from $428.8 billion under current law to $119.0 billion under the program.”
There’s a much better reason for employers to maintain a role in the health benefits decision process than the ones claimed by the NCB – benefits directly impact worker productivity. If employers are removed from the process of vetting and selecting health insurance vendors, individuals would be responsible for choosing their carrier. Insurance companies would ‘win’ based on how cheaply they could provide insurance to individuals and families, and the less care delivered, the lower the premiums. I don’t see what would prevent those vendors from suggesting each and every injured or ill worker or dependent tried bed rest and over the counter drugs for two weeks, then an x-ray or basic lab test, and only then would they get to see a diagnostician. In fact that’s how group plans treat back pain, while under work comp care is much more aggressive as it is focused on getting that worker back on the job.
Over time, those insurers who best manage chronic conditions (which drive most health care spending) will have lower costs and therefore deliver lower premiums. But the key issue is this – health plan incentives under an individually-driven system are different from an employer-based system. Over the long term, payers would figure out how to best care for medical conditions, and over that long term, the ones who do it right will win. However, that may not be the case over the short term – wherein low price based on denial of care or very conservative care would ‘win’ in the individual market.
Of course, studies show the number of employers who actually understand the linkage between health benefits and productivity is identical to the number of Yankee fans living within two blocks of Fenway. Yes, employers are ignorant of the real reason they should be involved in health benefits. But that doesn’t mean we shouldn’t protect them from themselves.
The net is this. The Healthy Americans Act would save employers a shipload of cash. It would also allow them to focus on running their businesses and get them out of the health plan management business. Those are good things.
Yet the impact of health benefits on productivity is undeniable – and has to be part of the cost:benefit calculus.

I’d been meaning to get to the Center for Studying Health System Change‘s annual Wall Street comes to Washington meeting for several years – finally made it and it has been well worth the trip from Conn.
There were two sessions, one devoted to health plans and the other to providers. I’ll be reading thru my notes today and tomorrow to come up with a couple unified-theme posts. For today, we’ll focus on what health plans are doing to prepare for health reform.
Panelists opined that there are two issues health plans have to address – dealing with the newly-insured and preparing for the possibility that the employer will not be the locus of control for health insurance purchasing. Christine Arnold noted that Cigna, Humana, and Coventry recently entered the individual market, with Aetna expanding its role while also acquiring Schaller Anderson, a veteran of the Medicaid world. UHC has been in the individual business for a while (post purchase of Golden Rule) and also has significant experience in the Medicaid and special needs populations (high cost, high risk Medicaid folks).
The individual market expansion is a hedge against McCain’s plan becoming the law of the land. As I’ve noted, McCain wants to discard the employer-based health system and rely on the market to cover individuals (while doing nothing to prevent medical underwriting or exclusion of pre-existing conditions). As Arnold noted, the individual market won’t cover many more folks unless there is a requirement for guaranteed issue and a significant penalty for those who refuse to enroll (otherwise they’ll just wait till they get sick, then sign up).
For those who question whether an individual program will work, Bob Laszewski noted that the Feds already have experience with a large scale, community-rated guarantee issue voluntary benefit plan – Part D. In terms of enrollment, the plan has been extra-ordinarily successful (despite my prognostications to the contrary). In terms of financial rewards, the numbers are good for those sponsors that excluded many of the most popular drugs, and pretty dismal for the two biggest players – Humana and UHC. These companies cover all of the most popular drugs, so seniors interested in a drug plan found the plans that covered their drugs and then checked prices.
And promptly used their cards and that’s why UHC and Humana are getting killed by Part D.
So what’s the lesson here? Health plans need to understand the individual market, but they also need to remember that benefit design drives adverse selection, which drives higher loss costs. While selling individual policies may seem like good preparation for a possible McCain-type plan, examining the results of Part D may be more instructive.

There are few issues that do more to crystalize the balance between personal freedom and personal responsibility than motorcycle helmet laws.
Twenty states require motorcyclists to wear helmets, which means thirty do not. Opponents of helmet laws see it is a personal choice and often claim wearing a helmet increases visibility and situational awareness. Could be.
Proponents of mandatory helmet laws note that fatality rates appear to be higher in states without helmet laws; common sense indicates that falling off a bike onto one’s head without a helmet is likely to cause a more serious head injury than if one was wearing a helmet.
And there is an ongoing back and forth debate on the merits of statistical analyses and the results thereof, a debate that leads nowhere and gets folks all wrapped up in numbers, thereby obscuring the real issue – ultimately wearing a helmet is a personal decision, until you get a traumatic brain injury, whereupon it becomes a societal issue.
Here’s an idea.
Those who want to ride without a helmet have to buy insurance that reflects that decision. That insurance must provide comprehensive coverage for medical care for associated with the covered individual, including long term custodial care, with a really high limit – say $10 million, that is indexed to the medical CPI to account for inflation. Upon showing proof of coverage, they get a special license plate. Insurance companies take the risk, society does not get harmed due to the adverse consequence of a personal decision, and those who want to ride with their hair blowing in the wind are free to do so.
Oh, and they should be required to be organ donors as well.

GOP Senators better wear their cheap suits while marching in Independence Day parades this weekend, as it is tough to get tomato stains out of nice wool.
As Bob Laszewski pointed out, Republicans were boxed into a very tight corner by their Democratic colleagues after GOP Senators blocked a bill that would have prevented a drastic cut in physician fees. The maneuvering was ugly, as the Dems apparently backing out of an earlier deal that would have restored the cuts. Once the bill was overwhelmingly passed by the House, Senate Democrats were presented with a very big cudgel they could use to smack their Republican colleagues around. And with Congress heading out for the 4th of July recess, they have done so – publicly, loudly, and repeatedly.
Republican Senators now find themselves defending their vote to reduce physician fees by 10% (that’s not exactly what happened, but close enough for politics) while refusing to reduce payments to big insurers. Payments that most view as far too generous.
Politically, the picture could not be better for Democrats. Republicans will be vilified for their vote to cut payments to Dr. Welby, everyone’s kindly neighborhood physician while continuing to pay huge sums to big, faceless, bureaucratic insurers located far away staffed by nasty clerks who delight in forcing new moms to leave the hospital mere moments after giving birth.
And in an election year too.
There is a good bit of substance to the argument against continuing the massive subsidies for Medicare Advantage (MA) and Private Fee for Service plans (PFFS). These payments were supposed to be temporary, used to motivate health plans to set up alternative Medicare programs, to make it worth their while to get started. Now that many of these plans have been up and running for several years, they should be able to survive on their own.
And as far back as 2005, health plans in these programs were doing just fine. In an example of exquisite timing a GAO audit revealed health plans in the program made over a billion dollars more than they expected; $1.14 billion in extra profit.
Yet healthplans are fiercely lobbying to hold onto the subsidies, and their GOP allies are marching in lockstep – right off a cliff.
Health plans, and their Republican allies, now look like they won’t pull their heads out of the public feedbag, even when it is obvious they are getting fat on taxpayer-funded subsidies.
Politically, both the GOP and health plans are being stupid. There’s no other word for it. Not only is this politically suicidal, the longer term implications are obvious. Health reform is coming, and private health plans will want to play a major role. They will claim that the market is the solution (a point I have also been making).
Yet these free-market companies continue to argue they can’t compete with the government-run Medicare program without massive subsidies.