Les Morgan

Conflicts over healthcare costs likely to increase

A new study (June, 2008) by the Commonwealth Fund finds that 25 million Americans are underinsured -- meaning they have health coverage but still have medical expenses they cannot afford. Commonwealth Fund president Karen Davis reviews the findings in her column. When added to the number of people who are uninsured at some point during the year, a staggering 73% of those with incomes below twice the poverty level are either inadequately or unstably insured. The number of underinsured has risen by 60 percent since 2003.

David cites the new study as evidence for her call for universal coverage that provides comprehensive benefits, saying:

"We cannot accept a health care system in which 42 percent of Americans under age 65 are uninsured or underinsured," Davis writes. "We must pursue a workable solution that mixes private and public coverage -- well before the majority of Americans find themselves with no coverage, or with coverage that has been chipped away until it no longer serves its purpose."

Davis and co-authors Cathy Schoen and Sara Collins spell out their own "Building Blocks" framework proposals for healthcare reform.

So which politician will wave the magic wand anf fix this? The Washington Post reports that Medicare and Medicaid are projected to devour half of all federal spending by 2050 ("Big Promises Bump Into Budget Realities" 21 June 2008).  The political unpopularity of cutting back on Medicare benefits was the reason for yesterday's dramatic House vote passing an eleventh-hour Medicare bill stopping proposed cuts to provider payments by a 355-59 vote, with 129 Republicans joining all Democrats who voted to approve the bill.  Stopping the provider reimbursement cuts is getting all of the attention but the House bill also contains a provision scaling back reforms to competitive bidding for durable equipment.  A New York Times piece comments that the rough sledding over competitive bidding is a foretaste of the resistance bigger-ticket reforms will have in the future. (See: "High Medicare Costs, Courtesy of Congress", 25 June 2008)

In California, where budget problems are as abundant as sunshine, a proposal to limit Medi-Cal benefits for some legal residents is getting mixed reviews. And our friendly pharmacists (among others) have filed a lawsuit seeking to stop proposed 10% Medi-Cal provider cuts as July 1 approaches.

As healthcare spending continues to rise, as demographically it must, we can expect conflicts of these sorts to intensify.

Technorati meets Twitter

I must confess that I am charmed by Twitter, the micro-blogging service.  It's a sort of haiku blogging, in which you get 140 characters to tell your story.  Thinking like a headline writer is good discipline!

"Tweets" (as Twitter posts are called) are short attention span soundbites that have low cognitive load, but potentially persuasive impact.  In an earlier era the office water cooler was the place where you could get a quick "heads up" on things, neatly summing up office politics with a wink and a nod prior to the formal memo coming out.  Twitter works in a similar way, like the water cooler for the blogosphere.  Quite a few bloggers use it to rapidly circulate tips on interesting content, hot news, and emerging ideas that may not be ready for prime time.  Some of these offhand tweets later show up as developed blog pieces, but most just pass by in moments as the river of Web 2.0 chatter flows on.

I have found that my Twitter feed is easier to update than my blog, so I now post news items mostly to Twitter.  My Twitter feed appears on the right side of my blog page so these sorts of short news links will show up in the blog location itself.  And today Debbie Ruder, the author of the Goodbyes blog, showed me how to add my Twitter feed to myTechnorati profile.  I didn't know you could do that, but it works. To learn how, check this simple how-to provided by Rita Wilhelm.

Debra Ruder On Goodbyes

I'm pleased to welcome Debra Bradley Ruder as our newest Growth House blogger. Debra is a Boston-based writer and editor with over twenty-five years of journalism experience. For the past ten years she has worked at the Dana-Farber Cancer Institute, writing about health care issues.

Her new blog Goodbyes will focus on conversations at the end of life. The idea grew out of a Harvard Medical School course called "Living with Life-Threatening Illness" in which first-year medical students got to know gravely ill patients. Toward the end of the semester, students were encouraged to say goodbye to their patients and thank them for imparting lessons they could carry into their medical careers.  Debra won the American Medical Writers Association 2007 Eric W. Martin Award for Excellence in Medical Writing for her feature story on that course, "Life Lessons" (Harvard Magazine, Jan.-Feb. 2006 issue).

Since then she has been collecting stories from people who had a chance to say goodbye and others who didn't.  Her pieces on farewells can teach us about what really matters in life.

Dying To Live

Dying To Live is a reality film by Ben Mittleman documenting his open-heart surgery for a leaking mitral valve, a genetic heart condition that had killed his father.  I recommend the film as an honest look at the emotional rollercoaster that serious illness can involve.  Mittleman is still alive and is doing well in Los Angeles.

The film will be released on March 13, 2008 in Los Angeles and will have a theatrical run of two weeks.  Les says check it out.

Most of the film consists of Mittleman's first-person narration, home movies, and conversations with others. There's no analysis of what's going on, and no statistics about prevalence of this or that.  Instead we get an unvarnished slice of life, with the filmmaker turning the camera on himself as he tackles some truly scary medical problems.

The interest of the film lies in Mittleman's range of emotions as he faces his own medical challenges and the illnesses of his loved ones.  Several of his family members die during the course of filming. Seeing so many of MIttleman's relatives cope with illness takes the film out of the purely self-absorbed category that some reality documentaries fall into. His mother was diagnosed with colon cancer, survives for several years, has brain surgery and finally dies. His Aunt Bess settles into an assisted living facility and finally dies. His dear friend Valerie is diagnosed with lung cancer that eventually proves incurable. He and Valerie decide to marry (after dating for 21 years) and Valerie receives hospice care prior to her death.  Valerie's aging houseman Sam has a stroke and throat cancer, progressing from assisted living to nursing home, finally dying under difficult conditions in which his advance directives were not on file with the hospital, resulting in unwanted insertion of a feeding tube.

The film gives us a direct look at the emotions of anxiety, fear, anger, and depression that often come with serious medical problems.  Mittleman's honesty in revealing his feelings is impressive.  You can view this as a rare type of "guy flick." Mittleman had worked as an actor, often cast as a beefy tough guy. We don't often get to see a man that looks like a football player being this exposed. His mood swings from angry rage to pained crying, sometimes within a few moments.  Men in particular will identify with some of the "guy moments." Prior to his diagnosis Mittleman had been very physically fit, so his declining physical capacity is a challenge to his sense of self.

With so much illness and death on the radar, you would expect the film to be a downer, but I did not experience it that way.  Instead, there is a positive, life-affirming tone that consistently keeps its chin up despite the problems.  Family, love, and the courage to keep going are quiet subtexts, without any preachy tone. 

We get enough glimpses of medical procedures to make us share the discomfort, but thankfully the film does not linger on them at excessive length.  The main focus is on what Mittleman is thinking and feeling as he tries to cope with life-threatening unknowns. His illness drives him to re-evaluate his values, his family history, and everything else about his life.  While he does not elaborate on his religious views, he draws strength from his Jewish heritage, which is reflected in family interviews, a conversation with a rabbi, and personal scenes.  He mentions Talmudic scriptures in passing as he reflects on what the experiences mean, but there is no preaching or deep philosophical discussion. 

Surprisingly, there is not a single mention of costs, insurance coverage, or other financial matters.  Many documentaries on serious illness give the impression that wonderful medical care just somehow happens.  Did the operation cost money?  Who paid for it?  Did Mittleman ever worry about the financial impact of his illness, including the loss of ability to work? These omissions aren't a reason not to see the film, but they do reflect the fact that the costs of care are often overlooked in films of this type. It's a good film anyway.  For more on the film visit: http://dyingtolivethemovie.com

California Healthcare Reform Battle Heats Up

California is currently engaged in one of the nation's most high-profile debates over health reform. The Health Care Security and Cost Reduction Act and a companion statewide initiative anticipated for the November 2008 ballot is intended to significantly reduce the numbers of the uninsured in California through public program expansions and increased employer participation in the health care of workers. The proposal is the result of a bipartisan effort by Democratic Speaker of the California State Assembly Fabian Núñez, Democratic Senate President pro Tem Don Perata, and Republican Governor Arnold Schwarzenegger. According to Núñez, California has 5.1 million uninsured, mostly low-income working individuals and their families. If the proposal is implemented, it would cover about 70% of them.

Núñez just posted a new blog piece saying that objections to the plan to reform health care in California "come from genuine proponents of a single-payer plan or those using single-payer as an organizing tool. Disappointment over the improbability of single-payer ever being enacted anytime in the foreseeable future should not be allowed to diminish the benefits millions of Californians will receive from the California plan."

Two things sruck me most about this piece. First, the Speaker of the California State Assembly is a blogger. Second, his comments amount to an indirect endorsement of a single-payer system as the best model for how things would be in a perfect world. Like many "practical" politicians he views a true single-payer system as a sort of Holy Grail of healthcare reform. His argument is that since he believes that a true single-payer system is not feasible to implement at this time, his plan is the best "real" alternative. Stephen Schear, an advocate of the single-payer model, just posted an Open Letter to California Single-Payer Advocates who oppose the current reform plan because it is not radical enough.  Schear argues that the incremental approach "creates structural building blocks that rationalize the health care system and therefore would make a transition to single payer easier."

Yesterday the Sacramento Bee ran a story on how business groups are lining up to oppose the plan. The bill mandates a sliding fee scale for employers - a minimum of 1 percent for payrolls up to $250,000 and 6.5 percent for those larger than $15 million. Employers would also be required to let employees pay their health insurance premiums on a pre-tax basis.

Assembly Bill X1 1 passed the state Assembly and is headed to the state Senate Health Committee on January 16, 2008. We can expect that discussion of California's stunning $14 billion budget deficit will take place there. It should be an interesting month.

Boobs On Ice - Peas, Cancer, and Social Networks

Today the Washington Post ran a story ("How Frozen Peas Started A Movement") about cancer survivor Susan Reynolds and her online support network of pea fanatics.  Reynolds, an artist, uses several social networking Web sites, including Twitter.  She started a blog called "Boobs On Ice" to document her experiences with breast cancer, including some practical tips on the benefits of frozen peas as ice packs following her mastectomy and subsequent reconstructive surgery.  The frozen peas became a rallying point for her online friends, and have snowballed into an online phenomenon.

Susan's story is a current example of how online social networking sites are serving an interesting function as a source of emotional support. Back in 2006 (a long time ago in Internet years) I wrote about the emerging phenomenon of blogging by people faced with serious illness ("Blogging Your Way Through Hospice"). Back then, Miriam Engelberg had just entered hospice care at the end stage of her battle with cancer. Miriam subsequently died, but Miriam's blog is still online as a record of her experiences with cancer, chemo, and caregiving.

U.S. ranks dead last in preventable deaths

The United States ranks dead last in a new study of preventable death in 19 industrialized nations. The study "Measuring the Health of Nations: Updating an Earlier Analysis" was done by researchers Ellen Nolte and Martin McKee of the London School of Hygiene and Tropical Medicine (Citation: E. Nolte and C. M. McKee, Health Affairs, January/February 2008, 27(1):58–71).

France, Japan and Australia had the lowest rates of preventable death, and the United States had the highest. If the US health care system performed as well as the top three countries, there would be 101,000 fewer deaths in the United States per year.

This puts another nail in the coffin for the idea that the United States has the best health care system in the world. According to the authors of the study, "[T]he findings presented here are consistent with other cross-national analyses, demonstrating the relative underperformance of the U.S. health care system in several key indicators compared with other industrialized countries." No one disagrees that the United States can provide outstanding care for some people. That "top tier" medical service is often touted to justify the belief that the United States has the "best system in the world." But access to that premium care is severely limited based on ability to pay. As Nolte said in an interview, "I wouldn't say it (the last-place ranking) is a condemnation, because I think health care in the U.S. is pretty good if you have access. But if you don't, I think that's the main problem, isn't it?" About 16% of the US population has no health insurance - about 47 million people.

Researcher Nolte said that statistic probably was a key factor in the poor showing of the United States compared to other industrialized nations. The research was backed by the Commonwealth Fund (commonwealthfund.org), a private New York-based health policy foundation. Commonwealth Fund Senior Vice President Cathy Schoen said in a statement that "It is startling to see the U.S. falling even farther behind on this crucial indicator of health system performance. The fact that other countries are reducing these preventable deaths more rapidly, yet spending far less, indicates that policy, goals and efforts to improve health systems make a difference."

For details see: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=640980

For a Reuters piece on this study (January 8, 2008) see: http://www.reuters.com/article/topNews/idUSN0765165020080108?feedType=RSS&feedName=topNews&pageNumber=2&virtualBrandChannel=0

The Details

In addition to the U.S., the study included 14 Western European countries, Canada, Australia, New Zealand, and Japan. The concept of "amenable mortality" was developed in the 1970s to assess health systems. This study used data from the World Health Organization on conditions considered amenable to health care in people under age 75. Causes of death that may be prevented by timely and effective health care include cardiovascular disease, some cancers, diabetes, some infections, and surgical complications.

Rates of mortality amenable to health care in the period 2002-2003 ranged from a low of 65 deaths per 100,000 population in France, to a high of 110 in the United States. Japan and Australia were almost tied for second place in the rankings, each with about 71 deaths per 100,000 population.

The United States also fell behind when you consider rates of improvement since the 1997-1998 period. Between 1997–98 and 2002–03, amenable mortality fell by an average of 16 percent in all countries except the U.S., where the decline was only 4 percent. In 1997–98, the U.S. ranked 15th out of the 19 countries on this measure, ahead of only Finland, Portugal, the United Kingdom, and Ireland—with a rate of 114.7 deaths per 100,000 people. By 2002–03, the U.S. fell to last place.

Grief Counseling Not Bad For You, Experts Say

My friend Dale Larson and his colleague William T. Hoyt have debunked the common notion that grief counseling often makes things worse rather than better in a new review of the scientific literature reported in the August issue of Professional Psychology: Research and Practice, published by the American Psychological Association (APA). You can read both the APA press release about it, and the full text of the article.

There is a lot of fuzzy thinking in this field, and this study is nice reminder that evidence matters. The flap is about “TIDE” (no, not the laundry product). In this context TIDE refers to treatment-induced deterioration effects. In other words, does seeing a grief therapist make things worse?

According to Larson and Hoyt, "A pessimistic view of grief counseling has emerged over the last 7 years, exemplified by R. A. Neimeyer’s (2000:541) oft-cited claim that 'such interventions are typically ineffective, and perhaps even deleterious, at least for persons experiencing a normal bereavement'". Neimeyer reported the alarming finding that, averaging over all studies that provided the necessary TIDE information, "nearly 38% of recipients of grief counseling theoretically would have fared better if assigned to the no-treatment condition". The results for “normal” grievers (as opposed to those who were "traumatically bereaved"), were even more alarming, with nearly one in two clients having negative effects as a result of treatment.

If this is true, having a cup of herbal tea would be cheaper and safer than seeing your grief counselor. These findings were quickly accepted as gospel fact, and were disseminated with lemming-like enthusiasm in the professional literature. Unfortunately, no one bothered to check the data behind these claims until now.

The APA press release on the new Larson and Hoyt article sums it up by saying that "Despite frequent claims to the contrary, there is no empirical or statistical evidence to suggest that grief counseling is harmful to clients, or that clients who are normally bereaved are at special risk if they receive grief counseling.... (Larson and Hoyt)... found that the data on which these negative views are based have never been published and came from a student dissertation that was never peer-reviewed, using a statistical technique attributed to another student’s master’s thesis, also never peer-reviewed."

Assuming that the analysis by Larson and Hoyt is correct, how is it possible that the dubious 2000 findings could have risen so quickly to be a popular mantra about grief support? It is not enough to simply criticize the sloppy initial publication. Why did it take this long for someone to notice problems with the work? The damage caused by the publication and repeated citation of the bogus TIDE claims is a case study of how the ideal of careful peer review broke down in this social science field.

Only recently, a separate post hoc blind review of the statistical methods was done by the APA, long after the widespread negative impact of the alarming findings had taken hold. The conclusion was that the methods were unreliable and that the findings cited by Neimeyer are "seriously flawed" (Larson and Hoyt: 349).

So how did this junk get past the original peer reviewers in 2000? Apparently none of those reviewers examined the original dissertation research. Instead, they trusted Neimeyer's summary of the dissertation findings. Once Neimeyer's summary was in the literature no one ever returned to the original empirical report to challenge its validity. This is like a hapless literature student who relies on the CliffsNotes for Moby Dick since it is an easier read than the original. That’s understandable, but I expect more from a peer reviewer.

Larson and Hoyt point out that "One factor that made the TIDE claims resistant to critical review was the practice of citing Neimeyer’s peer-reviewed summary article, rather than Fortner’s dissertation (which contained the data on which the claims were based).... The phrase 'novel statistical procedure,' which to a methodologist may be a red flag, appears in this instance to have leant added legitimacy to the findings among statistically naïve readers. If readers (and even reviewers!) lack the statistical training to evaluate new methodologies, this greatly enhances the chances for invalid findings, or misinterpretations of valid findings, to enter the published literature."

Larson and Hoyt (p. 353) suggest that scholars who don’t bother to read the sources they cite are "participating not in the conventions of scientific scholarship but rather in a sort of grown-up version of the children's game of 'telephone.' In this game, receivers later in the chain of communication never hear directly from the source but only from those just preceding them in the chain. In the grown-up version of the game, just as in the children’s version, there is every likelihood of serious distortion of the original message."

If you want to play telephone with Dale Larson you can probably reach him via his web site.

Medicare rate increase points to need for paradigm shift

On Friday, September 16, 2005, the Centers for Medicare and Medicaid Services (CMS) put out a press release announcing Medicare premiums and deductibles for 2006.

What struck me most about the official announcement was not the amount of the rate increase, but a suprisingly candid policy warning about what the future holds tucked away near the bottom of the text.  Most of the press accounts of this news only carried the lead paragraph, missing the more strategic part of the story.

As expected based on prior CMS projections, the Medicare Part B monthly premium will rise to $88.50 in 2006, an increase of $10.30 from the current $78.20 premium. CMS expects that despite the increase in premiums, most Medicare beneficiaries will have lower out-of-pocket health care costs in 2006 because the new Medicare prescription drug benefit will pick up the tab for some medication costs. About one-fourth of beneficiaries can receive assistance that pays for their entire Part B premium, and about one-third of beneficiaries can receive assistance for their Part D premium.

Why are rates going up? CMS notes that there has been a 9.9 percent increase in total Part B benefit payments. The text says: "Continued rapid growth in the intensity and utilization of Part B services is the primary reason for the premium increase. This growth is seen in physician office visits, lab tests, minor procedures, and physician-administered drugs. It also includes rapid growth in hospital outpatient services. Additionally, increased fee-for-service expenditures contribute to higher payment rates to Medicare Advantage health plans. Also, enrollment in Medicare Advantage plans is increasing as those plans have become much more widely available. These factors are leading to higher Medicare costs related to the Medicare Advantage program."

But wait, there's more! Near the bottom of the press release is the smoking gun:

"Some of these increases in use of services are unquestionably related to improvements in the quality of health care. However, as noted in the MedPAC letter and in subsequent analysis by CMS and other groups, much of the spending increase cannot easily be explained by changes in treatments based on new medical evidence and valuable new technologies.

As CMS has said repeatedly, the rapid growth in utilization of services shows that Medicare needs to move away from a system that pays simply for more services, regardless of their quality or impact on beneficiary health. Medicare payments should provide better financial support to doctors and other health professionals in their efforts to achieve better health outcomes for Medicare beneficiaries at a lower cost. CMS is working closely with medical professionals and Congress to increase the effectiveness of how Medicare compensates physicians and other health care providers. CMS is also conducting demonstrations and pilot programs that pay providers more for better quality, better patient satisfaction, and lower overall health care costs."

Translation: the current rate of increase in health care costs is unsustainable unless something improves in the cost-benefit ratio. Without qualitative improvements in the delivery system the only way to get lower health care costs is to provide less health care. You can expect that there will be increasingly difficult conversations between patients and health care providers as pressure mounts to contain costs. Want an elective procedure? Should you continue chemo despite lack of clear response? How about a liver transplant (on sale this week for only $250,000)?

Particularly when looking at care for the last years of life, a truly new paradigm is needed. Take a look at the Medicaring model as proposed by Joanne Lynn in her recent book Sick To Death. You can read the full text online at www.growthhouse.org/sicktodeath or at www.medicaring.org/sicktodeath.

Lynn's figures show that you can get better care at lower cost if you think about the care needs differently and apply an illness trajectory model with an emphasis on care continuity rather than episodic treatment. Do the math.

FY2007 Medicare Reimbursement Rates Announced

The Centers for Medicare and Medicaid Services (CMS) has released FY 2007 national payment rates for hospice care, with a 3.4% increase over FY2006.

This is a more generous increase than the proposed cuts that President Bush had requested.

The hospice industry may have dodged the bullet on outright cuts this time, but it's unlikely that pressure to control costs will let up any time soon. The staggering cost of health care for our aging baby boomers threatens to break the Federal bank. Half of all lifetime medical expenditures occur past age 65. In the United States, Medicare winds up picking up the tab for most of these costs at the end of life. For a quick review of how these costs add up check out Joanne Lynn's summary of the costs of care and who pays.  (The online edition of Sick To Death, Joanne's recent book on health care policy, is available at Growth House, by the way.)

The Federal government has few good alternatives for controlling escalating Medicare costs unless there is a paradigm shift in how end of life care is funded and managed. Band-aids aren't enough. And change won't be easy. Incremental cuts to hospice funding such as those proposed by President Bush in his FY2007 budget drew a lot of flak.

In February 2006 I did an interview for Growth House Radio with Jon Keyserling, Vice President of Public Policy and Counsel at the National Hospice and Palliative Care Organization, to explain the proposed cuts and get a better understanding of how the arcane economics of the hospice "marketbasket" influences reimbursement rates. You can listen to that interview or download it as a podcast (16:19, wma format).

These economic forces aren't always easy to understand or fun to discuss, but they make a huge impact on how care is delivered.  What's next for hospice finance?  To quote Bette Davis, "Fasten your seatbelts, it's going to be a bumpy ride."