Welcome to the Midsummer Health Wonk Review! The HWR had a break before this edition and will have a hiatus after this one too. So we’re borrowing from Shakespeare to set the stage a bit – we hope all of you in the Northern Hemisphere are enjoying the middle of summer! This edition of the HWR is jam-packed with excellent articles from some of the best writers in the healthcare blog world, and we’re honored to be hosting. We’re starting things off with a few articles that help to shed light on some aspects of health care reform that should be straight-forward but sometimes get a bit convoluted with political rhetoric. Then we’ve got several posts about corruption in healthcare and healthcare policy, and lots of posts that provide contrasting and well-reasoned viewpoints on healthcare reform and healthcare in general. And we’ll keep things cool with some winter and spring pictures we took around us here in Northern Colorado. Enjoy!
In an excellent piece debunking popular “wisdom” regarding immigrants and healthcare, Joe Paduda of Managed Care Matters explains that when it comes to the Medicare Trust Fund, immigrants put in a lot more than they take out: In 2009, immigrants paid in 14.7% of trust fund contributions but only accounted for 7.9% of its spending, with a net surplus of almost $14 billion. US-born people accounted for a deficit of almost $31 billion in the Medicare Trust Fund that same year. This appears to be a long-term trend: From 2002 to 2009, immigrants contributed $115.2 billion more to the Medicare Trust Fund than they received in Medicare benefits. Joe goes on to explain the details and warn those who rally behind strict immigration reform that they may want to rethink their position. Our Medicare Trust Fund would be in a lot worse shape without the immigrant population.
And if you’re curious about the implementation track for the ACA (and understandably confused by the constant talk of repeal, delay, replace, etc. that we keep hearing from some politicians) Linda Bergthold has what I consider to be a straight-forward and factual review of the situation. To sum it up, she’s predicting that the employer mandate will go into effect in 2015, as currently scheduled (following a one-year delay, but not a repeal), and that the individual mandate will be implemented in 2014, as planned. And while some states that delayed the creation of an exchange marketplace will likely have a tougher time getting everything up and running by 2014, the exchanges will be operational next year. I imagine there will be some bumps in the road as the ACA is fully implemented over the next few years. But we can work on ironing those out as we go – there’s no need to start from scratch.
Although the exchanges are likely to be successful in the long run, it won’t be without significant effort on the part of the people running them. At Health Affairs Blog, Barbara Markham Smith and Jack Meyer explain their recommendations for strategies that can help the exchanges be successful both out of the gates and for the long haul. They discuss pricing (don’t make it too high!) as well as communication/advertising programs that need to be unified, clear, concise and nation-wide in order to generate awareness and interest in as many people as possible. 
(Unfortunately, there’s a significant portion of the country’s leadership who seem to want the exchanges to fail – even to the detriment of the American people – and are content to spread mis-information about the entire law. This is a considerable hurdle that the exchanges will have to overcome.) Barbara and Jack recommend a temporary respite from the tax reconciliation that will be done to determine whether a person or family that received a subsidy is required to pay back a portion of it due to increased income compared with the prior year. And they also call for fostering increased competition and CO-OP creation in the states have not yet done so. All in all, pretty solid ideas for success in the exchanges and policy-makers would be wise to take heed.
I think of Dr. Roy Poses as the healthcare blog world whistleblower – he can always be counted on to expose nefarious acts in the healthcare industry, and Health Care Renewal is a must-read blog. Here is his take on the recent Transparency International poll that found 43% of US respondents believe that the US healthcare system is corrupt, and that 64% believe that the government is run by big money and special interests. Roy notes that unfortunately, most of the media coverage of the Transparency International poll has focused on world-wide data and/or specifics from far-away lands. Instead of focusing on our own serious problems with corruption in healthcare, it seems that a lot of media outlets (keep in mind that media is sometimes beholden to special interests too…) prefer to present the problem as something that happens in other countries as opposed to something that we need to work on here in the US.
Continuing with the corruption theme, Eric Turkewitz of the NY Personal Injury Law Blog shares a multi-part series about Dr. Katz, who has been rebuked for lying on the stand in a personal injury trial that resulted in a mistrial because of the doctor’s actions. Central to the issue is the practice of independent medical exams (with the word “independent” being very loosely used in this case) conducted by doctors who are hired by insurance companies when they are defending personal injury cases. Dr. Katz makes a 7 figure income 
from his medical-legal practice, but in one case that has been made public, he grossly over-stated the amount of time he spent with a patient (he claimed it was 10 – 20 minutes, but a secretly-made video recording of the visit showed that it was under two minutes). Eric has looked at additional data and found that the average length of Dr. Katz’s exams was around 4 minutes. Additional details on this story are here. Wow. The doctor was obviously concerned first and foremost with money, but the insurance companies who hired him were likely not doing due diligence to make sure that he was providing accurate data. They may have been more concerned with finding a doctor who would tell them what they wanted to hear rather than the actual details of the patients’ medical cases. Sad all around, but sadder still is the fact that it’s probably not all that unusual.
And for a little more on the cronyism/corruption topic (maybe those corruption figures Roy mentioned from the Transparency International poll were skewed a bit too low?), Patrick Paule of InsureBlog writes about agencies and individuals who have been involved with the Obama Administration for some time, and are now finding themselves in lucrative financial and/or influential positions as the ACA gets implemented. In other words, business as usual in the government. Government appointments, grants, etc. are often awarded this way (ie, appearing to be rewards for donations and/or loyalty), in every administration, regardless of which party is in power. There’s ample room for opponents to cry foul, but it also has to be pointed out that presidents and secretaries and others in power have to be able to select people they trust for top leadership positions. And trust is earned over time. There’s a fine line between selecting the right candidate for the job, having that person be someone trusted by the top officials, and avoiding cronyism. I don’t know what the right answer is, but it’s easy to see how the appointments and grants and leadership roles being handed out with the ACA could be construed as rewards for political support and loyalty.
At Health Beat, Maggie Mahar writes a thoughtful and thorough review of Miriam Zoll’s Cracked Open: Liberty, Fertility and the Pursuit of High Tech Babies. After reading Maggie’s article, I’m eager to read the book itself (Maggie leaves a bit of a cliff hanger at the end…). Assisted reproductive technology is certainly a blessing to many families. But it can also be fraught with problems that stem from both overly-optimistic expectations on the part of patients (and society in general), over-promising on the part of providers, and a medical field that is largely unregulated and often not covered by health insurance policies.
At Health Business Blog, David Williams explains his skepticism about DealWell, a new Priceline-style website for healthcare services. I am very much in favor of increasing transparency in healthcare pricing and moving away from the proprietary pricing system we have now, where even the most dedicated patient “shoppers” can find it impossible to obtain real healthcare prices before having a procedure. And to that end, I love the
idea of a website where people can bid on the care they need and providers can accept or decline the offer depending on their current workload and the payment offered. But David makes some excellent points about the downsides: not being integrated with health insurance is a big one, especially since nearly everyone will have to have health insurance starting in 2014 (even if a procedure is lower than your deductible, it makes sense to stay in network and have the amount you pay be credited towards your deductible, in case you need additional care later in the year). Although DealWell might be a good option for people looking for one-time services that aren’t covered by health insurance (such a LASIK or a dental implant or fertility treatment, for example), it’s probably not going to be the next big thing in healthcare price transparency.
Over at Disease Management Care Blog, Jaan Sidorov takes a closer look at the glowing picture painted by CMS regarding ACO pilot programs, digs a little deeper, and gives us a slightly less rosy view of the results. And there’s even a T-Rex analogy, to keep things even more interesting. Jaan points out that the ACOs that didn’t meet the pilot program goals are likely feeling the sting of losing millions of dollars, since the initial investment costs are not cheap. Although 9 of the 32 pilot ACO providers have said that they want to leave the program, I wonder if results will be better as time goes by, mitigating the initial investment costs somewhat? Stay tuned.
Julie Ferguson of Workers’ Comp Insider writes about the July 6th 777 crash at SFO, detailing how the flight attendants did an excellent job of putting their emergency training into practice, saving lives in the process. Julie notes that while it’s easy to shrug off emergency plans simply because we rarely come face-to-face with an emergency, such preparedness can mean the difference between life and death. Does your business have a solid plan in place to deal with emergencies? Has everyone at the business been trained on it? How fast can your building be evacuated if necessary? All good things to think about.
Writing at Health Access Blog, Anthony Wright discusses the one-year delay of the employer mandate portion of the ACA that will require employers with more than 50 employees to provide health insurance to eligible full-time workers. Anthony makes some very important points: the delay doesn’t impact anyone’s eligibility for health insurance and/or subsidies. People who would have been offered health insurance from an 
employer with the employer mandate in place will still be able to get coverage through their state’s exchange – and if they make up to 400% of the federal poverty level, they’ll qualify for subsidies to help pay for it. In addition, the vast majority of large employers in the US already offer health insurance to their employees and have historically done so without a mandate requiring it. It’s unlikely that a large amount of those employers will suddenly drop their coverage in 2014. But Anthony goes on to note that if the delay were extended for additional years, it could begin to destabilize the financial foundation of the ACA and employers might begin to shift more workers onto exchange plans, relying on tax-funded subsidies to foot a portion of the bill.
The Healthcare Economist, aka Jason Shafrin, brings us a great summary of health insurance in China over the past half century. Until the end of the 1970s, there were three main health insurance systems in China that covered nearly everyone. But the wheels started to come off after that; by 1998 almost half of the urban population had no health insurance, and by 2003, 95% of the rural population in China was uninsured. In the last ten years, China has tackled health care reform in order to try to remedy the problem. While plenty of progress has been made, there is still a long way to go.
Jared Rhoads has written a review of The Autistic Brain by Temple Grandin. His review is a good read, and the book looks like it is as well. Professor Grandin teaches at Colorado State University – my alma mater – and consults for the livestock industry as well as being a bestselling author. She’s an inspiring and accomplished person even without taking into account her own autism. Her book combines her personal 
experiences with the latest that science has to offer us with regards to autism. If you’re interested in autism, Jared’s summary is that this book is a good place to start learning more. I’m adding it to my list of books to read, so thanks for the tip Jared!
John Goodman lays out some of the results of the ACA thus far (fair enough, but keep in mind that most of the law hasn’t been implemented yet). He details some positives and negatives, both expected and unintended, although his overall take is that the ACA is not a great solution. Strongly worded opinions about the ACA will likely meet with a round of applause from one side of the political spectrum, and boos from the other side. But regardless of your position, I would say that it’s tough to argue with John’s point about high deductible, consumer-driven health plans. I think he’s correct in saying that they’re probably going to be quite popular starting in 2014, when they will be among the least-expensive plans available. This is probably particularly true among people who won’t qualify for subsidies.
That’s it for this mid-summer edition of the Health Wonk Review. Many thanks to Julie and Joe for keeping such a great blog carnival going all these years! The HWR now has a summer hiatus. Don’t miss the next edition on August 15th, which will be hosted by David Williams at Health Business Blog.
