Insight, analysis & opinion from Joe Paduda
Minna Jung at the Robert Wood Johnson’s blog on reform is this biweek’s host of Health Wonk Review. If you thought the first round games of the men’s NCAA hoops tourney were crazy, you’ll think it was all tranquilio when you read her post.
an excellent review, with some good forecasting as well
Yesterday’s news that the CBO estimated the reform bill will come in under the Democrats’ $950 billion over ten years (after revenue increases) was good news for reform advocates.
But the analysis didn’t account for the $250 billion plus deficit that’s hanging over Medicare like Damocles’ sword. As I’ve reported previously, Medicare physician reimbursement will change – and when it does that deficit will be added to the nation’s debt.
That’s not to say the CBO erred in their cost projection. They are required to base their calculations on current law, and current law has physician fees slashed by over 20% this fall.
That is NOT going to happen. And therefore the real cost of the Medicare program is going to be at least a quarter billion dollars higher than CBO projects.
Not even the most intense civics class would have prepared you for the theatrics coming our way in Congress.
I’ve read several articles about the Democrats’ strategy to get reform passed and signed into law and the GOP’s efforts to block reform. There’s at least a semester’s worth of study just in the Congressional manueverings, with a full year required to flow the Senate processes, parliamentary rules, and political manupulation thereof.
Politico has a pretty good synopsis, with the net being this.
1. The House has to pass the current Senate bill as is.
2. There are provisions in the Senate bill that are repugnant to many Dems; they will pass a ‘sidecar’ bill to address those provisions which will then go to the Senate.
3. The Senate Republicans will seek to delay the vote in the House and Senate thru debate, asking for votes on amendments to peel away Dem votes, and seeking rulings from the Senate parliamentarian on points of order. These last are a key part of the Republican strategy as the rules for what can and cannot be passed thru the reconciliation process are arcane and complicated.
4. If the Dems are successful, they will seek a vote that only requires 51 yeas, and the reform will pass.
It’s anyone’s guess if that will happen. If it does I’ll be looking closely at the final bills to ferret out the key provisions…
Posted via iPhone so typos are probable.
Loyal readers, return with us once again to the wilds of North Dakota, that ice-bound region where executives are criminalized for signing off on cookies and balloons at farewell parties, where out-of-control prosecutors deny defendants their constitutional rights, where a boss not from NoDak is pilloried despite turning around a troubled state agency.
Yes, the Sandy Blunt case has reached a new peak of incomprehensibility. Here’s the latest.
Blunt appealed his conviction to the State Supreme Court a year ago, and the case was argued five months ago. One would think that would be plenty of time for the judges to issue a ruling. After all, the Court issued seven opinions so far this year for cases argued in 2010 – two months after Blunt’s hearing.
And while logical minds would think that speedy justice, a right of all citizens conferred in the US Constitution would apply in the frozen north, apparently that is not the case. (See below for the requirements of other courts in North Dakota)
In fact, of the twelve opinions rendered by the North Dakota Supreme Court, not one was argued before Blunt’s – all were argued a month or more after his, yet the Court has not seen fit to issue a ruling in Blunt’s case.
Which leads to the next fascinating bit of NoDak current events.
Reports indicate the attorney who prosecuted Blunt is under investigation by the State Police for potential crimes including conspiracy. What makes this so interesting is that no other media outlet reported this until well after Steve Cates did in his “Dakota Beacon’.
Wait, it gets weirder.
On the day that the State Police announced the investigation into the Assistant State’s Attorney who prosecuted Blunt (Cynthia Feland), there were two other stories that actually did make the news. One would think that they must be big, if they took precedence over an investigation into potential crimes by a Prosecutor. Perhaps a bust of a huge crystal meth lab? Reports of Al Qaeda coming across the border from Canada?
Nope.
Two men, described in the media as “Native Americans” (gotta love that unbiased media…) were caught on video breaking a liquor store window and stealing fifty bucks worth of booze.
Let’s see…I’m the producer of local TV news, got two minutes to fill on the crime blotter…fifty bucks in booze, about four bottles perhaps, against allegations of criminal actions by a county prosecutor…hmmmm, seems like a pretty clear editorial decision to me – let’s slam the Native Americans! Who cares about a law enforcement official accused of conspiracy and suborning justice!
This would actually be pretty funny, even hilarious, if it wasn’t about a prosecutor who allegedly committed crimes in the course of prosecuting one of the most decent, honest, and competent executives I’ve had the honor of meeting in my 25 plus years in the business world.
(Here’s the relevant language from North Dakota’s Judiciary)
Section 1. Statement of Policy.
a. A goal of the judicial system of North Dakota is prompt disposition of cases.
b. The Supreme Court recognizes the need to provide administrative mechanisms within the unified judicial system to maintain current trial court dockets. These trial court docket currency standards and procedures are established to meet this administrative goal.
c. These standards guide the management of the trial courts of North Dakota. However, these court management standards and procedures are not intended and may not form the basis to change or affect the substantive and procedural rights of the parties in any case. Further, a violation of these standards does not cause the dismissal of any case.
d. Adherence to these standards by trial judges requires lawyers to recognize consequent adjustments in local practice. Members of the bar should anticipate the prompt disposition of cases.
Yesterday’s news that US industrial production continued to improve was a welcome sign of good news for a work comp industry that has been hammered by declining claims frequency, increased severity, horrible investment returns, and a recession that prolonged what was already one of the longer soft markets in memory.
Notably, manufacturing, long a weakening sector, has shown solid strength of late, particularly in New York, where new orders were up substantially over February’s figures. Employment in the sector was also up significantly to its highest point in two years.
As NCCI has reported, injury rates tend to spike up during an economic recovery as the pace of work speeds up, full-time workers get more hours and overtime, and new, less-experienced workers are hired.
What to watch for
The New York Fed typically is among the quickest of the 12 Federal Reserve Districts to report economic data; other Districts will be reporting over the next few days. As New York, along with the rest of the mid-Atlantic and northeastern states were hard hit by winter storms, economic activity may well have been suppressed by factory closings.
The other Districts may well report sharper increases, and if they do that’s good news for the comp business.
What does this mean for you?
Injury rates are going to increase, as is the raw number of injuries. While bad news for the affected parties, this will be positive for occ health clinics, case management and bill review companies, pharmacy benefit managers, TPAs, and other servicing entities.
Insurers will find this a mixed bag, as an increase in injuries means higher claims costs. However, better investment returns, and what appears to be a ‘de-softening’ of the comp insurance market is as welcome as it is overdue.
In what must be one of her more enlightened statements, Tea Party diva Sarah Palin told a crowd of Canadians that in her youth, “We used to hustle over the border for health care we received in Canada. And I think now, isn’t that ironic? “
You betcha.
That from the same person who has repeatedly referred to her good fortune in obtaining ‘good union jobs with great benefits’…
Big tip of the toque to Maggie Mahar for the info.
Medicare Set-Asides are one of those narrow but very deep niches in the workers comp (and other insurance lines) business that look simple at first glance, but are anything but.
The Federal government, more specifically the Center for Medicare and Medicaid Services (CMS) requires payers to submit MSAs for claims that meet specific requirements.
There’s been a good deal of confusion about reporting requirements, controversy over how to estimate future drug costs, concern over delays in processing MSAs by CMS vendors, and disputes over the vendors’ judgments. A lot of this is inevitable, as MSAs are a fairly recent phenomena governed by CMS’ myriad and sundry rules. But inevitable or not, the confusion and lack of clarity on deadlines, reporting and funding requirements and submission standards are causing significant problems for all involved.
There are currently two efforts to resolve much of the confusion and concern. WorkCompCentral reports a bill has been submitted to the House that addresses many payer (and CMS) issues. According to Safeway Risk Manager Bill Zachry;
“The bill was developed by the Medicare Advisory Recovery Coalition (MARC) to focus primarily on liability issues, but a number of the provisions will also affect insurance carriers and self-insured employers with respect to conditional payments and reporting of workers’ compensation payments and obligations.
The primary features of the proposed bill include:
1. Providing a specific time frame and process to be used in
determining MSP required payments before settlements
2. A right of appeal for Non-Group Health Plans with respect to MSP
obligations
3. Sensible MSP Recovery Thresholds
4. Taking Social Security Numbers (SSN) and Health Insurance Card
Numbers (HICN) Out of the Reporting Process
5. Setting a Statute of Limitation for MSP claims
6. Establishing safe harbors and clarity with respect to MMSEA §111
reporting penalties
7. Establishing a modest user fee designed to assure that the reforms
in the bill do not raise cost issues in the scoring of the bill.”
There are also indications that CMS is listening to vendor complaints, as it has recently extended the deadline for electronic submission to the end of this year. CMS is also looking for vendors to process the MSA submissions, and is asking interested parties to bid on the contract.
Click here for more details or if you’re looking to support MARC’s efforts,
I’ve been avoiding posting on health reform of late, mostly because I’m so dismayed by what’s happened, and what’s happening.
The Republican Congress passed and then-President Bush signed into law Medicare Part D which added about $8 trillion to our national debt.
Now the Democrats want to one-up the GOP by passing what would be a massive entitlement expansion, with no meaningful cost containment. They want us to believe we can expand coverage now and fix the cost issue later.
No, we can’t, and no, we won’t. It is far more difficult to get people to give things up they already have than to convince them they can’t afford those things in the first place.
The health care reform debate has provided all the evidence we need to see how hard it is to get physicians, or insurance companies, or unions, or voters, or employers, or state regulators, or pharma, or device companies to agree to give back business/rights/revenue/coverage they have today.
Bob Laszewski said it well in his post today –
“adding 30 million more people to an unsustainable system expecting it will create an even bigger crisis and thereby force real reform is tantamount to reboarding the Titanic in the hopes it will sink faster. It is also hard to see how doing such a thing is the politically courageous thing to do.
Just where is the moral imperative in ramming a trillion dollar entitlement expansion through knowing full well it will make our long-term deficit nightmare even worse–for those now uninsured and for everyone else?
The Democratic health care bill makes little if any systemic changes to the health care system–certainly not at the level we need.”
Neither party is acting in the best interest of the nation, or of their own constituents for that matter. And anyone who believes we can pass it now and fix it later is living in a fantasy world.
One example proves the point. The bill presently under consideration doesn’t address the ongoing issue of Medicare physician compensation, a failure that precisely illustrates the problem of passing it now and fixing it later. Medicare physician compensation legislation was passed a decade ago, with hard and tough limits on physician reimbursement. Yet every year Congress votes to overturn the cuts, with the result that we now have a $300 billion deficit in the program.
What does this mean for you?
Not only is sausage making ugly to watch, it produces inedible results.
Prostate cancer may be one of the most over-diagnosed and over-treated conditions in the nation. It is also one of the most over-publicized, with ex-politicians (Bob Dole) and sports figures (Ed Randall) encouraging all men over 50 to get a test that is no more accurate than a flip of the coin, costs big bucks, and may well lead to costly, unnecessary, and painful surgery.
In an editorial in today’s NYTimes, Richard Ablin, who discovered PSA (the enzyme that is the target of the test), publicly disavowed the test, calling it a “hugely expensive public health disaster”. He went on to detail the statistics: “American men have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent chance of dying from it. That’s because the majority of prostate cancers grow slowly. In other words, men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it.” [emphasis added]
The cost of prostate hysteria comes to about $3 billion a year for the tests, plus the pain and discomfort and sexual dysfunction – and cost – of men treated unnecessarily.
One study found “1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent one death from prostate cancer.”
Another study found “94% of the cancers detected with the routine PSA blood test would not cause death before the age of 85.”
What’s really disturbing about this is the evidence was there 15 years ago. I wrote a paper for a now-defunct journal describing the results of AHCPR’s Prostate Outcome Research Team which documented much of the problems described by Dr Amblin today. Yet the science is hard-pressed to overcome the marketing muscle behind the test, muscle that has been used to develop fake grassroots organizations supporting the testing (aka astroturf). These organizations are funded by companies who benefit not only from the test, but the devices and seeds used to ‘treat’ positive results.
Here’s one example.
Michael Milken, the principle founder of the Prostate Cancer Foundation, is a significant investor in the venture capital industries. Are you aware that Michael Milken founded Proquest Investments, a $1 billion venture capital fund, with a specific investment thesis centered around prostate cancer after founding the Prostate Cancer Foundation? If you review the board members to ProQuest, you will find that six of the seven scientific advisors to ProQuest Investments are executives or member doctors to the Prostate Cancer Foundation. It seems clear that ProQuest Investments operates as a for profit extension of the Prostate Cancer Foundation, a 501(c)(3) designated non-profit
.
This not for profit encourages testing and screening, resulting in millions of unnecessary tests, thousands of impotent and incontinent men, and billions in revenue for the physicians, device and pharma companies, and facilities providing the testing and treatment.
What does this mean for you?
Payers are wasting money, patients are getting unnecessary treatment, and physicians are violating their oath to do no harm. Which category are you in?
Note – I’ve contacted Ed Randall, the host of the popular (and very good) Talking Baseball radio program several times in an effort to encourage him to stop promoting PSA testing. He’s never responded. I encourage you to contact Mr Randall yourself here – http://www.erbatforthecure.org/ and ask him to reconsider his advocacy that harms patients and increases costs while benefiting for profit companies.
Next month I’m going to be speaking at the Geisinger Clinic on the subject of Comparative Effectiveness – the payer’s ethical dilemma. I’m fascinated by this issue as it strikes at the heart of the problems with, and perhaps solutions for, the health insurance crisis.
If we are to solve the access and cost problem, payers, providers, and patients must be comfortable with the decision process and methodology. Today, there’s precious little ‘comfort’ with the current ‘system’. And that’s understandable.
There’s a lot of ‘art’ in medicine; physicians diagnose conditions and recommend specific treatments based on what they think will help, often without much in the way of peer-reviewed research supporting their views. Much is based on their own training and experience and the knowledge passed on to them by their medical school professors and colleagues, provided in specialty society and other medical journals, passed on by medical device and pharmaceutical firms, and learned at conferences and symposia.
Most of the time this knowledge delivers the ‘right’ outcome; the patient gets better. But in some instances there are at least a couple different treatment options for the patient’s condition. Physicians recommend what they think will work based on the patient’s unique characteristics (physical, emotional, financial, history), and these ‘recommendations’ may be several. For example, chronic lower back pain treatment options may include surgery, physical therapy, medications, some of the above, all of the above, and variations of each of the above.
Sticking with the back pain issue, think of this from the payer’s perspective. The wide variation in back surgery rates is well-documented, with Medicare data indicating a 500% variation between Ft Myers and Miami Florida. We don’t know why there’s such a wide difference, but it is safe to assume that the rate is too high in Ft Myers, too low in Miami, or perhaps both.
When a physician in Ft Myers recommends surgery for a patient with a back condition, it is understandable why payers would have concern over the appropriateness of the procedure. To address this concern, payers utilize clinical treatment guidelines in an effort to determine if the recommendation is ‘appropriate’.
In some cases, the guidelines provide clear and convincing support for or against the procedure, but in many others the finding is not so clear cut. The patient may have some but not all of the clinical findings that are ‘necessary’ to support surgery; there may be other medical conditions present that complicate treatment determination; the patient may want one type of treatment for their own reasons.
The result is the payer – and the physician – are functioning in a somewhat grey area.
There are obvious financial factors in play as well. The physician gets paid to do the procedure, the pharma company gets paid if the patient takes their meds, the device company gains revenue for each device sold, the payer saves money if expensive procedures aren’t performed, the patient may want drugs for inappropriate reasons.
The ethical issues are apparent. While we would hope that decisions would be based solely on the evidence, there often isn’t enough of the right type of evidence to arrive at a clear cut decision. When that occurs, what other factors affect the decision? How are disagreements resolved, and what is that resolution? When there’s strong disagreement, what factors, evidence, criteria are ‘used’ to support the parties’ different positions?
If you have experience with situations that speak to this ethical dilemma, I’d appreciate hearing from you.
