Feb

The Anthem rate increase – the reality behind the politicking

Posted by Joe Paduda on Monday, February 22nd, 2010 | Comments

Anthem Wellpoint’s announcement that it was raising premiums up to 39% for members covered by their California individual insurance product hit at a really bad time – for Anthem.
HHS Secretary Kathleen Sibelius reaction was immediate and blunt, as she ordered a federal probe into the rate hike.
“It remains difficult to understand how a company that made $2.7 billion in the last quarter of 2009 alone can justify massive increases that will leave consumers with nothing but bad options: pay more for coverage, cut back on benefits or join the ranks of the uninsured.”
She’s right, as far as it goes. And things heated up even more last week, with the release of a report on insurance rate increases around the country.
To justify the increase, Wellpoint claimed
_ healthy customers are dropping coverage to save money while sicker ones retain it and run up medical bills
_ healthy customers also are switching to cheaper insurance options, further dinging revenue
_ some customers are moving into a higher age category that carries higher premiums
_ deductibles and co-payments haven’t gone up with inflation
_ prices for medical care are rising
_ people are using more health care, again, age is a factor
Here are the facts
1. The individual business accounts for 10% of Wellpoint’s California membership, or about 600,000 members. (other reports indicate this figure is higher, but this comes from their state filing)
2. The average rate increase will be about 25%.
3. Data from their filing with the state appears to refute Wellpoint’s claim that membership is declining, as it actually increased over the year.
4. The claim that healthier members are dropping coverage while sicker, more expensive members remain in the plan is likely valid. This is what happens when rates go up and healthier people, who have the option of joining a cheaper plan, leave while the members with pre-existing conditions who can’t find adequate, affordable coverage have to stay with their current plan.
5. Despite claims fro Sibelius et al, Wellpoint is not that profitable; while it did make $2.7 billion in Q4 2009, most of that was from the sale of their PBM division. In total Anthem (the parent company) made $4.7 billion last year on $65 billion in revenue; a 3.1% profit margin (on ongoing operations, discounting the one-time profit from the PBM sale).

And here’s the editorial view.
Health insurers are not that profitable; as an industry, net profits were 2.2% in 2008. I’ll stipulate that this is in large part due to a lack of creativity and foresight on the part of insurers, coupled with a demonstrated failure to do what they’re supposed to do – deliver good coverage at affordable prices. Most insurers are not much more than transaction processors and provider aggregators.
Another example of the insurance industry’s ~~willingness~~ ongoing penchant for shooting itself in the head. Health reform is clearly a highly politicized topic, yet just a couple days before the rate increase was announced, Wellpoint settled a dispute in California by agreeing to take back 2330 members they had terminated after those members had the temerity to actually submit bills for medical care.
Who could possibly have predicted the hue and cry? That a big rate increase after settling a rescission dispute would raise the ire of politicians while the nation’s debate on health care reform is still at full volume?
What does this mean for you?
Perhaps this will do the industry some good, as the focus on profits will reveal insurance companies aren’t making big bucks, and politicians will start searching for other, more meaningful areas to address.
Doubtful.

Feb

Update – Zenith sold to Fairfax

Posted by Joe Paduda on Friday, February 19th, 2010 | Comments

Yesterday I said
“Kudos to Worker Comp Exec, they were the first” to get the notice out about Fairfax’ purchase of work comp insurer Zenith for $1.4 billion.
I should have said Work Comp Exec was the first to send the notice to
me, as WorkCompCentral posted their news a bit earlier on their site.
Yesterday’s post appears below; first the analysis.
Good move by Fairfax. Zenith is one of those rare WC insurers; it doesn’t follow the suicidal market cycles, buying business in the soft market and running for the hills when the market hardens. CEO Stanley Zax has built a solid management team and the addition of Janet Frank (sources say she was aware of the deal and will assume the presidency of Zenith) adds additional strength.
So why now?
My take is Fairfax recognizized the market is about to turn, and decided to buy now before the stock price went up. They don’t want companies in turnaround mode as Fairfax ‘buys and leaves alone’. And if the market turns by the end of this year (as I’ve been predicting) they wouldn’t have time to fix a broken insurer. Fairfax wanted to expand their footprint with an insurer well-positioned to benefit from a hardening market, and Zenith fits that need quite well.
This represents a premium of about 30% over the current stock price, welcome news for any and all Zenith shareholders. The market appears to believe the deal, scheduled to close in the second quarter, will get done as Zenith is currently trading just shy of the stated purchase price.
Zenith will reportedly continue to operate independently; this isn’t a surprise nor is it one of those “yeah, sure, until the dust settles’ proclamations as Fairfax tends to allow its subs, which include Crum and Forster and Odyssey Re, to chart their own course.

Feb

Dr. Phil’s lessons for reformers

Posted by Joe Paduda on Thursday, February 18th, 2010 | Comments

There have been many creative themes for Health Wonk Review, but none more than Brady Augustine’s channeling of Dr. Phil in this week’s edition.
Brady’s point is at this time of increasing polarization we would do well to step back and try to identify and coalesce around some common goals, objectives, themes.
If we don’t, the health system we deride today will be much better than what we end up with in ten years’ time.
Oh, and you’ve got to watch the Jon Stewart video clip…

Feb

How’s Coventry doing?

Posted by Joe Paduda on Tuesday, February 16th, 2010 | Comments

Pretty well.
With the demise of health reform and the company’s continued focus on core businesses at the expense of ancillary or unrelated operations, things are looking up for the mid-tier managed care company. Last week’s Q4 2009 earnings call revealed a number of positive results while acknowledging significant ‘headwinds’ exist in the health plan business.
Since CEO/Chair Allen Wise resumed leadership of Coventry over a year ago, he’s done a creditable job turning things around despite a tough business environment. While there’s still a lot left to do, Coventry is clearly back on track, despite projecting commercial medical trend of 8.5% – 9% for 2010.
Wise et al dumped the Medicare fee for service business last year along with First Health Priority Services [note FHPS is NOT the workers comp bill review/network/case management business], moves that removed burdens while adding to the overall company’s profitability. There were a number of management changes as well, particularly in regional health plans and sales, that appear to be bearing fruit.
Coventry, like most other health plans, is facing declining enrollment. With employment numbers still troublesome, they are going to lose membership on the commercial sector side but will continue to raise prices to ensure profits grow.
One of the more encouraging statements in the call was from Wise, and pertained to medical management (an area long neglected by Coventry):
“we must do a better job in managing our members’ product care needs. And to that end, we’ve embarked on several initiatives and put considerable resources to improve this area. It’s difficult to do, but we understand that providing better care and more cost-effective care for our members is basic to stay in this business.”
Although this was specific to the Medicare Coordinated Care business, it is one of the first indications that Coventry is working to move from a company solely focused on risk selection and price arbitrage to one that is at least thinking about medical management.
Workers comp
Many MCM readers are interested in Coventry’s work comp operations, so here’s a few items of potential import.
First, Wise said:
“Some comments on our remaining businesses, which is our fee-based businesses. And that’s our workers’ compensation services, our rental network, and the federal, the FEHB business, which are all stable with improving results, well-positioned and produce a diversified revenue, earnings and cash flow stream while capitalizing on our core managed care capabilities. During 2009, we spent time addressing the administrative cost structure for these areas and improvement will continue during 2010.”
Coventry cut a lot of overhead in the WC unit in 2009 and earlier this year, and word is more reductions are on the way.
Second, and more obtuse, was a discussion about hospital unit costs and their impact on trend (which was described as ‘high single digits’). Coventry personnel described their efforts to recontract with hospitals to address trend, particularly as it effected Medicare costs. Not sure how or if this affects work comp, but some of Coventry’s work comp customers have been seeing significant increases in facility expenses.
Something to watch for.
What does this mean for you?
Watch your facility costs – particularly the price per service and volume of services, and especially for ER visits.

Feb

How many dollars are wasted on physical therapy?

Posted by Joe Paduda on Friday, February 12th, 2010 | Comments

Probably a lot. Perhaps most. And certainly a big chunk of the bucks your insurer/TPA is paying.
Unlike surgery, imaging, drugs, and other types of medical treatment, PT has long been a bit of a black art.
The clinical guidelines for PT that do exist (with one exception I’ll get to in a minute) usually say something like ‘two visits a week for four weeks’, without describing what is to be done during those visits, who’s supposed to do what gets done, and equally important, what shouldn’t be done.
That’s the primary reason physical medicine (PT and chiro) accounts for about one out of every five dollars spent on medical care in work comp, and would account for big bucks in group if it weren’t for tightly written benefit limits (x visits at a 50% copay).
Before the PTs out there start flaming me, know that I’m a believer in the ability of appropriate PT and have seen lots of data that support the use of PT in helping injured folks return to functionality. But I’ve also audited many work comp claims where the claimant had been to PT hundreds of times. I recall one where the claimant had over five hundred (500) visits over a three year period, with each PT note looking identical to the previous one. The payer couldn’t cut off the treatment because the treating physician had ordered it, and the clinical guidelines weren’t robust enough to force the issue in court.
Last month the NYTimes had an excellent article by Gina Kolata on just this issue. Here’s an excerpt:
“My doctor at the Hospital for Special Surgery in New York, Joseph Feinberg, seems to share my opinion [that much of PT is waste]. “Very often, I think the hot packs, cold packs, ultrasound and electrostimulation are unnecessary,” he said, adding, “For sure, in many cases these modalities are a waste of time.”
So has physical therapy been tested for garden-variety sports injuries like tendinosis? Or is it just accepted without much question by people who urgently want to get better?
It depends, says James J. Irrgang, a researcher in the department of orthopedic surgery at the University of Pittsburgh and president of the orthopedic section of the American Physical Therapy Association.
“There is a growing body of evidence that supports what physical therapists do, but there is a lot of voodoo out there, too,” Dr. Irrgang said. “You can waste a lot of time and money on things that aren’t very helpful.”

(not in Ms Kolata’s article, but helpful for perspective…)
Sometimes, manual stretching by a physical therapist can actually eliminate a sports injury, he said…They are the exceptions. More common are the “voodoo” treatments, he said. And what might those be? None other than ice and heat and ultrasound, Dr. Irrgang said.
Ice and heat, Dr. Irrgang said, “can control pain a little bit” but “are not going to take care of the problem.” The underlying injury remains.”
But the lack of credible evidence-based clinical guidelines can make it difficult for payers to contest unnecessary treatment, especially in those states where regulations make it tough for payers to stop paying for unnecessary treatments.
There are credible, thoroughly researched clinical guidelines specific to PT, with the best focused not only on how many visits over how many weeks, but what should be done during those visits. I’ve reviewed all of the guidelines used in work comp for PT, and the most thorough are published by Expert Clinical Benchmarks, a subsidiary of MedRisk. (MedRisk is an HSA client)
Guidelines can’t be developed in six months; rather they must be carefully researched, assessed by acknowledged experts in the field, tested against claims and medical billing data, and reviewed periodically. There are far too many companies touting their ‘utilization review’ programs which are based on little more than the ‘same old same old’ guidelines that have never worked in the past, or quickly-assembled amalgamations of journal articles, neither of which will be of any help in front of a work comp judge.
What does this mean for you?
If you’re serious about managing PT, start with science.
UPDATE
I received an email from a good friend and colleague in the PT business who felt my post was an insult.

Let me reiterate – there are good PTs, and bad PTs.
There is good PT management, and bad PT management.
Some PT is quite useful, appropriate, and necessary, and some is not. When payers don’t use solid clinical guidelines it makes it very difficult for adjusters, case managers, peer reviewers, and hearing judges to differentiate between appropriate and inappropriate PT. And there’s lots of inappropriate PT in work comp.
In the course of my consulting practice, I’ve seen dozens of cases where claimants received more than a hundred PT visits over a year, and many where the total number was well over two hundred. This type of utilization is simply indefensible, and unfortunately often results in adoption of regulatory control mechanisms.
Some states have chosen to use caps on visits as proxies for utilization management, with 24 appearing to be the most common limit. This is at best a blunt instrument, but nonetheless it appears to have resulted in lower costs for physical medicine in the jurisdictions that have adopted the ’24 visit rule’.

Feb

The role of the PBM in workers comp

Posted by Joe Paduda on Thursday, February 11th, 2010 | Comments

Work comp drug costs account for about one-sixth of medical expenses, and are increasing at a rate appreciably higher than overall medical cost. Why?
And more importantly, how are some payers able to keep drug trend negative?
I’ve just come from CompPharma’s annual meeting in St Pete: CompPharma is a consortium of work comp PBMs run by myself and Helen Knight. Nine of the nation’s eleven largest PBMs are members and together they account for over 75% of work comp drug spend. From conversations with the PBMs, and from discussions with work comp payers there appears to be a couple attributes that are consistently present among those payers enjoying low drug trend.
They partner with their PBMs. The succesful payers don’t tell, direct, mandate or demand, they listen, ask, analyze and collaborate. Most of all they recognize that their PBMs know a lot about managing drug spend. This shouldn’t be a surprise as that’s the reason PBMs exist. Sure, many also provide ancillary services but in most cases these are very much ‘ancillary’ to pharmacy. These payers take advantage of their PBM’s deep experience, the knowledge gained from working with many payers for many years in many states. They understand what works and what doesn’t, and why.
The other distinguishing chararcteristic has to do with size. Smaller payers are seeing better results in terms of drug cost inflation than their larger competitors. This may well be due to their slower adoption of cost controls; in the past larger payers implemented more cost controls sooner and they saw lower trend than smaller payers. So some of this may well be ‘catch up’.
But catching up required smaller payers to set up, implement evaluate and fine tune multiple pretty sophisticated programs, without the staff, funds, and resources of the big boys. Instead they turned to their PBMs, a decision that has paid off handsomely.
This isn’t to say all PBMs are equal performers and worthy of consideration; there are bad actors in every business.
What does this mean for you?
Maybe you should ask your PBM what they would do if they were in your shoes. And do it with a VERY open mind.

Feb

What reformers and their opponents should know

Posted by Joe Paduda on Wednesday, February 10th, 2010 | Comments

I’ve never had a guest post on MCM but an email from a colleague inspired me to ask if I could publish it not as a comment but as a post.
The writer addresses the issues laid out in my post earlier this week about the inherent conflicts in many Americans’ desire to pay lower taxes while getting whatever care they want from whomever they want.
Here’s the guest post.
Your most recent posting and photos brings to mind a case I am now reviewing of a woman who is suing a nearby city for a sidewalk fall. She has more than a decade of treatment and I have gone thru over 4000 pages of files for everything from GI problems, multiple orthopedic interventions including several ineffective spine and knee surgeries, obesity, migraine, ‘fibromyalgia’, history of hysterectomy at young age for pelvic pain, multiple bouts of depression and anxiety, history of domestic abuse, opiate dependence, multiple work comp, auto and disability claims. Her pharmacy records alone are a 59 page printout from 2006 through 2009. Providers include primary care, GI specialists, Gynecology, MSW, Psychiatry, Psychology, ARNP, chiropractors, massage therapy, acupuncture, neurosurgeons, orthopedists, physiatrists, physical therapy, neurology and some I have may be forgetting. And the file even includes over 100 pages of emails to and from the patient and the various providers.
I could go on. My task focuses mainly on causality of the recent injury claim to her back and spine complaints. As a psychiatrist I have been engaged along with other physicians because of the big picture; emotional issues are likely significant or primary drivers for her multiple somatic complaints, surgery, narcotic consumption and life decisions in general. Her demands for this injury are about $600,000 according to the referring attorney, with the inference being that her current problems are the result of a minor slip and fall in 2006.
I found myself wondering how much her care has cost the rest of us and how little of the care had any real value in terms of doing anything meaningful for her health and her life. She currently has chronic multi-system pain complaints, history of multiple surgeries without obvious underlying pathology or positive outcome in most cases, and she is now opiate addicted. My impression is that there may be more than a million dollars in care that she has received over the past decade or more. It is far from clear whether health reform would in any way change this for better or worse but she represents the Pareto principal (ie 80/20 or 90/10 or 95/5 rule in her case) in practice and she is far from alone. I am likely one of the minority of people engaged in the health debate who actually see individuals that reflect the problems we face in society and in health care. This case is an example of how we as a society medicalize emotional and social problems and the extraordinary level of waste represented by many medical interventions, to the degree that the interventions side-step or avoid what is really going on – but spend extraordinary resources in the process. Most practitioners can likely share similar stories from their training or practice, but it seems to be a secret hiding in plain sight. Consider the difference between this scenario and the meager resources available in much of the world for life changing and saving care. The cost of her care could vaccinate large geographic regions in the 3rd world and actually save lives if we could somehow reallocate the resources.
I find it interesting that some folks like us are willing to pay more in taxes for a better society, while we likely use relatively little in terms of government services – while many who rely on government largesse, like those riding power chairs because they are too lazy to walk, who may be collecting their own Social Security and Medicare while perhaps pulling out far more than they ever put in – are holding tea parties. Many of these protesters are one pink slip away from no health care and no income, yet they protest for who and for what?

Feb

Have their cake, eat it too, and have someone else pay for their gluttony

Posted by Joe Paduda on Monday, February 8th, 2010 | Comments

The recent demise of the health reform effort was killed in large part by Americans’ overwhelming demand for more and more, while wanting to take less and less responsibility.

Uwe Reinhardt’s recent column describes the problem quite well.

Americans want government to make sure that they have at their beck and call the most sophisticated health system in the world, without even a hint of a queue or rationing or balancing of benefits and costs (cost-effectiveness analysis).
At the same time, they rail at town hall meetings and in the voting booth against government intrusions into that health system, and wring their hands incessantly over the height of health insurance premiums and the taxes they pay to support the system.

Of late, many have turned to threats of violence, that is, if they can maneuver their Medicare-funded power wheel chairs close enough to get a shot.

While it’s easy to condemn the manipulators (60 Plus et al), their job wouldn’t be so easy if their pawns had even a modest grasp of linear logic – A (stuffing yourself with junk food and drink) leads to B (obesity) leads to C (diabetes, heart disease, and the need for a power wheelchair paid for by someone else).
Example:

These goals are mutually exclusive – the deficit cannot be controlled without drastic reductions in health care costs, which some will interpret as rationing. Yet these same pawns that protest against ‘government hands on their Medicare’ are also screaming about deficits, taxes, and the future burden on their children.
This terminal myopia will not prevent the inevitable – growing deficits driven in large part by their incessant demand for someone else to pay for their lifestyle choices and freedom to get whatever health care they think they want from whomever they want whenever they want.
There’s more than enough blame to go around over the demise of health reform; as I’ve written numerous times, the Dems passed bills that would have done little to actually control costs. But the Republicans didn’t offer any serious alternatives, when they could have made a clear and principled argument that the bills under consideration would add to the deficit, resulting in higher taxes and government borrowing.
Instead the GOP rallied around death panels, rationing, and keeping government out of healthcare, torching any pretense of leadership on the altar of political expediency. They’ve painted themselves into an unescapable political corner; when they once again gain control over Congress, they will be faced with a deficit that includes $8 trillion from the Medicare Part D program (a Bush 2 legacy) along with Medicaid and Medicare costs that are even more unsustainable due to their refusal to confront their supporters with economic reality.
As HL Mencken said, “People deserve the government they get, and they deserve to get it good and hard.”

Feb

Break out the champagne, but don’t loosen the cork

Posted by Joe Paduda on Saturday, February 6th, 2010 | Comments

The light at the end of the tunnel is getting brighter – and closer.
Yesterday’s jobs report contained good news for the economy and for the workers comp industry – unemployment dropped 0.3% to 9.7%, a rate that is still way too high, but better than last month’s 10% and certainly headed in the right direction.
The details are even more encouraging – the first gains in manufacturing jobs in two and a half years (!) (+11,000) and a small uptick in hours worked per week.
The other good news is a sharp bump in temp workers (+52,000), and a huge drop in the “number of persons who worked part time for economic reasons (sometimes
referred to as involuntary part-time workers) fell from 9.2 to 8.3 million in January. These individuals were working part time because their hours had been cut back or because they were unable to find a full-time job.” (source BLS)
This last statistic is telling; sometimes called the ‘underemployment rate’, the data indicated a result of 16.5 percent in January, a welcome improvement from December’s 17.3 percent.
Construction and transportation continued to suffer, with both sectors seeing continued declines in employment. However, there are a number of significant projects funded by the American Reinvestment and Recovery Act, including a major nuclear site decommission on the Savannah River that will result in the hiring of up to 3000 workers.
There’s also a report that new home construction in the Atlanta area is picking up, improving the fortunes of developers and laborers alike.
Hiring is slowly increasing, and the ever-so-slight uptick in manufacturing, the first in two and a half years, is hopefully a leading indicator.
When employment picks up, so does work comp premium, and inevitably claims. The good work by NCCI indicates the injury rate typically heads up at the end of a recession as employees are working longer hours and more overtime, the pace picks up, and less experienced workers are hired.
What does this mean for you?
Higher work comp premium volume, more injuries, and more work for managed care and claims organizations. I’d expect safety and loss control people to start getting more calls as well.

Feb

Health Wonk Review – so, what do we do now?

Posted by Joe Paduda on Thursday, February 4th, 2010 | Comments

If ever there was a time to be writing about health reform, this is it.
It’s an even better time to be reading about health reform. Is health reform dead, or is it just snoozing, waiting for a Prince Charming to lay on the smooch it needs to reawaken, full of promise and hope?

(hint, this guy doesn’t look much like Senator Brown…)
Before we get to the next chapter in the story, we’re going to hear from clinicians and politicians, policy gurus and providers, health administrators and educators, insurance brokers and Medicaid advocates, IT pros and pharmacists – in short just about everyone fits under the big wonk tent.
And where better to start than down in the trenches, where the real problems with our health care system are all too visible. Merrill Goozner kicks us off with an excellent summary of the new news on why hospital costs vary so much across the country – hint, NYC is pricey not because of high wages, but because CMS pays hospitals a ton to educate doctors and two tons for dispro. A great example of how unseen factors influence employers’ – and taxpayers’ – costs.
Drug prices are one source of consternation to many, with price control advocates complaining about big pharma’s unfettered ability to set prices, and free market fans countering that without that ability pharma couldn’t afford to develop new meds. A post that should get both thinking comes from David Williams, who describes how a pharma company is losing out, while patients are benefiting, without taking sides. A thought-provoking piece to be sure.
Julie Ferguson sends in an a synopsis of what could be a really fun development. Now that 14 states allow medical marijuana, when will it be part of a workers comp drug formulary?
For the real druggies among you, Adam Fein does a deep dive into the world of drug pricing and the future thereof.
Glenn Laffel asks why all the companies fighting over the Feds’ $19 billion allocated to electronic health records are offering guarantees that their version will meet HHS’ standards (hint – if they don’t, users stand to lose big bucks).
And finally, back to the Gooz, who’s penned a report on how the once-promising area of personalized, genomicly-specific cancer care is off to a very slow start.
Wrapping up the discussion of health care at the ground level, we welcome the Robert Wood Johnson Foundation to HWR. The RWJF blog team (what, they have a whole team? man I’m some kinda jealous!) posts on over-utilization of diagnostic imaging. Their post is a terrific synopsis of how several communities and provider organizations have reined in MRI spending by using clinical guidelines. Great stuff!
Jaan Sidorov wants the Obama administration to get crackin’ and name a head for CMS. He wants a fresh face and strong leadership for the folks who run about 40% of our health spending. Not a bad idea…
And when they do, the new boss should start working on long term care. Kyle Pinion reports that this is one area of health care that is in desperate need of fixing, specifically to address some of Medicaid’s deficiencies.
Sleeping Beauty could sure have used a little LTC – can you just imagine the poor gal’s bed sores?
At the state level, the purpling of Massachusetts sent shock waves thru the political landscape and got several contributors thinking hard about the ‘whys’ and ‘what nexts’. The general sense is now-Senator Brown is not looking to step into the Prince Charming role anytime soon (although he did vote for Mass’ health reform).
Tinker Ready’s piece asks if “Voters Reject[ed] the Massachusetts Health Reform Model?, and the sense is – they may have, but not because they didn’t want reform, they just didn’t want reform ‘lite’.
Who needs health insurance?!
All the way across to t’other side of the country, we find Anthony Wright walking us thru Rush Limbaugh’s recent encounter with what may be the most ‘socialized’ medical system in the country – Hawai’i. Limbaugh has a great solution to the health insurance problem – don’t buy any. He’s figured out how regular Americans can get by without coverage. The man’s a geenyus!
But wait, perhaps Rush isn’t so bright…I’m betting Jennifer Lyon wouldn’t think so, because she was also ‘self-insured’, at least until she passed away from breast cancer. When asked why she hadn’t seen a physician earlier. Lyon said, “I didn’t have insurance, which is a big part of it. And it really wasn’t changing much. But a year later, I felt another lump, and then I felt something under my armpit.” Read more here.
Oops, back to the drawing board, big (and I don’t mean tall) guy…
Well, at least Limbaugh doesn’t have to deal with insurance companies – lucky guy. Over at the Digerati Life, the Ms DL laments; well, no, that’s much too weak an adjective – we’ll go with detests – dealing with insurance company claim forms resulting from her family’s decision to go PPO instead of HMO.
Roy Poses MD has been a HWR’er since our denouement, and always gets the award for post no one else would have thought of. This ed. it’s about three California health centers with notable quality issues, that somehow still managed to pay execs big bucks in the form of incentive payments. Roy says “The rationale for these bonuses, given out at a time when the university system was under major financial constraints, was that they were incentives for exemplary performance and patient care.”
Peggy Salvatore weighs in on a study that says people trust their providers more than the government to protect the privacy of their health care data. (don’t these people read the news?!)
As we say in New England, Go figure…
So without reform, what happens…
Well, some believe reform is still possible, others don’t. We’ll start off with a point-counterpoint minus the hair pulling and hurling of invective – courtesy of Health Affairs. Henry Aaron wants the Senate bill enacted and ‘fixed’ in reconciliation. For those who have dismissed this out of hand, Aaron’s piece may well make you reconsider. The counterpoint comes from Joseph Antos; he wants incremental reform including the ability for insurers to sell policies across state lines…
Brad Wright agrees with Aaron, as he also thinks reform may not be dead yet, but it will require passage of the Senate bill by the House and making changes via reconciliation.
And long time HWR’er Hank Stern disagrees with Antos (when it comes to health insurance, Hank’s a very knowledgeable guy, so perhaps Antos should be calling Hank).
But wait, Mike Feehan, a colleague of Hank’s, agrees with Antos, noting that this might also address the issue of mandates and force more competition.
Joanne Kenen of The New America Foundation laments the lack of primary care, the lack of real funding for primary and preventive care, and the impact the demise of reform will have – more of the same. And costs will therefore increase to deliver care that should never have been necessary. Sigh.
David Harlow opines that all is not lost, and lays out his wish list for reform now that Senator Brown is, well, Senator Brown. David believes reform can happen without the bigwig pols getting involved.
Friend and colleague Maggie Mahar doesn’t want any initial reform effort to start with ending the insurance industry’s anti-trust exemption, calling the current interest in this move ‘pandering’.
Brady Augustine is a bit more – ticked off. In his contribution, he asks the insightful, yet idealistic question; “How can Congress expect providers to work together in interdisciplinary teams and accountable care organizations if it is unwilling to do the same?” Brady believes reform should have come from the middle. Me too.
Louise in Colorado (one of the best health insurance bloggers in the ‘sphere) has a very interesting suggestion on how to address pre-existing condition exclusions without an enforceable mandate. Go read it.
On the macro-est level, we welcome John Goodman, who believes reform is not about health reform but about collectivism, and more specifically how we shouldn’t let government take over health care. Goodman says “in matter of health, private decision-making is socially intolerable”. Ed note – I disagree, strongly with the premise and the conclusion.
The Incidental Economist thinks the real problem is political feasibility, and that’s where things went so horribly wrong.
Alas, we close this chapter (it’s bed time for your faithful author) leaving this story to the next HWR editor – Brady Augustine at medicaidfirstaid.com. He’s an old hand at this editor of HWR stuff, and has the honor of hosting the Fourth Anniversary Edition!
He’ll let you know if the smooching’s started

Author: Joe Paduda