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Naomi Freundlich
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Harry and Hoyt, To lump the CLASS Act in with the overall effort to reform health care is a tactic used by those who are dead set against the ACA which, by the way, was passed into law over a year ago. It was always a far smaller effort, there were always questions about its ability to be self-sufficient--especially in light of what other readers have said about people being incapable of thinking about long-term care before they actually need it. I do not believe that Obama promised that CLASS would save $70 billion; but rather it was envisioned as a program that would take some of the burden off of Medicaid and, interestingly, would shift some long-term care to the consumer-driven model conservatives seem so fond of. That it failed is really a function of the lack of an individual mandate or other strong incentive that would increase participation. The Affordable Care Act, of course, does have an individual mandate. So your statement about past experiences with failed health insurance exchanges just doesn't make sense. Perhaps you're talking about high-risk state insurance exchanges, where only those denied insurance because of pre-existing illness participate--but those are not at all like the ACA's planned exchanges. For the rest of the commenters (TDP, DA, Joe, JS), I agree that we can't continue to think about long-term care as something separate from medical care--it is far too interwoven. For now, payment for nurses aides, nursing homes, and other care for the elderly will be paid for by a mix of out-of-pocket, Medicaid, Medicare (through the increasing number of people choosing hospice services)and for a minority--through private long-term care policies. But this is an untenable situation as our population ages and lives longer--not necessarily healthier--lives. CLASS is a program with a lot of good ideas and potential. Its current failure may force a deeper discussion about long-term care, an issue to be dealt with in the next wave of reform.
Toggle Commented Oct 21, 2011 on A CLASS Act Failure at Health Beat
Hi John, Just wanted to give you the heads-up that I wrote the HealthBeat article about the demise of the CLASS Act, not Maggie. Also, if you want more information about Medicaid managed care plans, there is a Medicaid Commission (similar to MEDPAC)that published a report recently on managed care in the program. You can access the report here http://www.macpac.gov/reports. Thanks, Naomi Freundlich ~~~~~~~~~~~~~~~ Forgive me, Naomi. Careless oversight. Now fixed. You do good work, by the way. JB
Marc, Brian Thank you for your comments (Brian, fyi I wrote this article, not Maggie Mahar). There seems to be some inconsistency here between how the FDA compiles data internally and what is made public to those trying to access it, as Brian Overstreet and his colleagues at AdverseEvent.com are suggesting. I think I was clear that AdverseEvent is a for-profit start-up and has piqued interest in its services because of a perceived lack of information on drug side effects. Perhaps the two of you have connected off-line about this area; I'm interested in hearing more... Naomi
ng I agree with you on the dental access issue. There have been many cases over the years of private parties suing state Medicaid programs and the issue of equal access remains poorly defined. This is the first to reach the Supreme Court; if the ruling stands, there could be a lot more lawsuits demanding better access to care--dental or otherwise.
Hoyt, Comparing the federal government's health reform plan to Gaddafi's rule is reason enough to ignore this comment. When a group enlists corporate members to help craft legislation out of the public's eye that is then meant to repeal or seriously impair a federal law, I'd call that sabotage.
Pat S. Not sure why this study is now behind a paywall, I was able to access a pdf version yesterday with no problem. But yes, there were other interesting figures on access to care included in the working paper, thanks for pointing some of them out. Naomi
Thanks for all the comments, I have gained some real insight into how the coding issue is really much bigger than just an issue of disparate and error-plagued systems. Pat S. thanks for doing the research to find this report on fraud in the private insurance market--we do hear a lot about Medicaid and Medicare and it's interesting to find out that fraud is just as prevalent in the private sector.Will have to look into this more. Although, I have to admit that I'm not surprised; I have witnessed "up-coding" and a wide range of other direct attempts to "game" the private insurance system. I never quite understood why my GP insisted on having his nurse drag in a portable EKG machine and also administer a "blow" test at every visit--even for a sore throat. It seemed that they could stay ahead in the game just by regularly charging for these services and take what what they could get in reimbursement. But what strikes me is that at the micro level (as we've said hundreds of times before)there is a significant amount of waste, fraud and poor organization that adds up to a considerable drain on health care costs. This exchange of comments just makes that more clear to me.
Panacea,Jenga First of all, there is overwhelming scientific evidence that cigarettes and other tobacco products are dangerous and in my opinion should really be taken off the market as other dangerous consumer products have been. Taxing tobacco and strengthening anti-smoking laws effects all smokers (and curtails the practice), no matter their income level, and brings in needed revenue for state budgets. Perhaps some of that should be directed (as the original tobacco settlement money was)to anti-smoking efforts and cessation programs. Singling out Medicaid recipients for consuming a legal and heavily promoted product is just unfair. As for obesity, it is a complicated medical problem with a variety of causes--including some that are less straight-forward than merely eating too much. Many medications cause weight gain, disability can lead to obesity and as I discussed in the post, it's a lot cheaper to buy three boxes of mac and cheese, potatoes and junk food than purchase ingredients for a salad and poached salmon dinner. The current economics of nutrition leave poor people at a severe disadvantage--making them pay for being obese without offering alternatives makes no sense. There are plenty of fat Americans (2/3 of the population is overweight)who are not covered by Medicaid and are not forced to pay a fine for their corpulence. So, Jenga, I do support taxing cigarettes and junk food (artificial tanning too) so that the price of these products better represents their deleterious effects on everyone's health and associated costs. I just can't see the logic of singling out one vulnerable portion of society to meet stringent standards of healthy behavior when social determinants often make it so difficult to achieve them. Carolyn, Thanks for the reference to the NICE dilemma--it is a good illustration of the slippery slope we head down when we start penalizing people for certain behaviors that are linked to injury or disease.
Jenga, Several readers have posted their response to your take on shared decision making and patient-centered care and it's clear you don't agree with them or with me. These are both very positive ideas in health care--involving the patient and his or her individual priorities (age,overall health,level of activity,extent of disease--as well as personal factors and beliefs) in making decision about treatment. I'm sure you can agree (and you've stated several times in this thread)that one-size-fits all medicine is not doing any one good. No one has said that PCI should never be performed and stents are completely useless. But as Pat S. has reiterated, study after study has shown that in most people with stable coronary artery disease medical therapy is just as good and should be the first line of treatment. If you choose not to tell patients this information and instead go straight to PCI you are practicing poor quality care and even putting your patient in harm's way. Rhino powder may not be a great analogy but what about radical masectomy vs. lumpectomy for certain types of breast tumors. For years surgeons ignored evidence that survival and recurrence rates were the same for both procedures (and led women to believe otherwise)and subjected them to the more radical surgery and far more serious side-effects because it was a practice they believed superior and were used to performing. It wasn't until patient rights groups made this an issue of informed decision making (or patient-centered care, whatever...)that radical mastectomy stopped being routinely performed for all tumors.
Right now, shared decision making goes something like this: the interventional cardiologist says to the patient,"look, the evidence recommends that I put you on meds for x number of months and hopefully your blockage will widen. But, I could use this fantastic new stent to prop open your artery while you're already on the table and when you wake up you're going to feel great, no more pain, etc." Imagine that scenario but with the doctor playing up drug therapy, citing risks of PCI and telling the patient that Medicare won't cover most of the cost of the intervention. If that's what you mean by shared decision making or informed consent than I agree with you.
Thanks to all for the comments and adding to the discussion. Jim, rather than being a "peripheral conversation" that misses the "real issues" I think some of the ideas presented for dealing with high malpractice rates both in these comments and in some of the AHRQ's demonstration projects will have a far more beneficial impact than caps,high financial barriers or other limits on the ability of patients to sue. As reader Greg Pawelski puts it; "Limits on the rights of people hurt by medical malpractice will victimize them and their families further while helping neither patients nor doctors. The real beneficiaries will be insurance companies, including the doctor-owned malpractice insurers." So, no, I absolutely do not agree that we should "give tort reformers what they want..." What they want is unfair, leads to no benefits in patient safety and stifles more innovative ways of dealing with the malpractice insurance cost problem. Pat S. writes, "tort reform, while comforting to doctors, has not had any real impact on spending or spending growth in those states (Texas and CA). Both are, in fact, examples of what is worst in US health care spending." He recommends expert panels to hear malpractice cases--this is worth investigating. I also agree with Sharon MD that doctors "need to confront our lack of comfort with being wrong every once in a while. We also need protection from being sued if we follow standard guidelines of diagnosis and treatment." Mediation, expert panels, safety initiatives, better documentation--these are all approaches worth considering. Naomi
Jenga, I appreciate your comments on this post, it is always instructive to hear from someone who has firsthand experience. I agree that doctors often end up using devices they are trained on--and this is often decided by which company funds the training. Having good service sounds important too. But I would argue that it would be in the interest of patients, as well as our health care system to have more evidence-based methods for deciding which implant is most effective. Medical devices are not really comparable to cars and no one is advocating for a law that just a few implants can be sold. But if insurers base reimbursement on effectiveness and need--not on physician preference--everyone will profit (except maybe some device companies.)
Jim, This has nothing to do with "big government" and everything to do with the recognition that advance directives and end-of-life planning are just as crucial to high-quality medical care as life-saving treatments. Yes, many doctors talk to their patients about these issues without the incentive of being paid. But some 60% of critically ill patients and their families have never had these conversations. And no, it isn't the responsibility of some other expert to have this discussion--the primary care doctor is the patient's conduit to all medical care and should know and respect his wishes. Adding it to a list of "preventive" services that are covered by Medicare isn't going to make a huge difference financially for doctors, and it's not going to stop anyone from promoting treatment at all and any cost that might extend life; even against a family's wishes. But it does represent a movement forward in how we as a society deal with the huge problem--both in terms of cost and quality of life--that is end-of-life care. An RN, You may have a point there that RNs or other practitioners may be better suited to have these kind of discussions with patients than doctors--I'm not in a position to make that call. John, I agree, thanks for putting the collective disappointment into words. Naomi
Yes, Arizona, thanks John
Thanks John, I got rid of them. Ironic that they spammed a post about data mining and free speech...
You are right, our blog does have tracking software, although it doesn't give complete identifying information. Some visitors obviously have some blocking software that prevents information from coming into TypePad's tracking system because many of fields are labeled "Unknown." Basically I can use sitemeter to see how many people have come to the site, and in some cases what page they entered and left on and what server they use to surf the web (but not their name or other account info), what city/town and state they are located in and how long they spent on our site. This is useful only in that it helps us see which posts are most popular with readers and also gives us raw info about how many folks are visiting our site. I would classify this kind of data gathering as "benign" since we aren't marketing anything, aren't storing the info and basically just use it to help ourselves feel better that someone actually is reading what we wrote. Period. If you would like to opt out, please feel free to do so, I just have no idea how that is done! Naomi
Brad, The Maine law is less restrictive than those in New Hampshire and Vermont in that it requires doctors to "opt-out" of the data mining process--kind of like putting yourself on a do-not-call list for telemarketers. The other difference is that both the Maine and NH challenges were heard in the same Boston circuit court, whereas the Vermont case was heard in NY. But Kevin is correct that there are actually two issues at play here; free speech and privacy. Courts will have to decide whether prescriber's (and patient's)right to privacy outrank protecting the "free commercial speech" of data miners.
Jim, I think I make it clear in my post what's wrong with the Wyden/Brown bill: It effectively sabotages the ACA before it even has a chance to get off the ground. As far as Ron Wyden's leadership in health reform, his plan (authored with Utah's Sen. Robert Bennett)was rejected because it would have set up a new free-market private insurance system that would eventually take the place of employer-sponsored coverage, Medicaid and SCHIP. The basic concern, detailed in this analysis by the Center on Budget and Policy Priorities http://www.cbpp.org/cms/?fa=view&id=674 is that because of adverse selection, these private plans would end up being too costly for poor and disabled Americans and would ultimately add to the problem of unaffordable insurance for those with pre-existing conditions. Wyden's general slipperiness (he's for the individual mandate, he's against it; he voted for ACA, now says he wants to change it, etc.)and affinity for the private insurance industry make it difficult for me to see his plan as worthy of a serious test.
Chiropractic, Can you give us some more info about who you are and why you are leaving USPTF? Hannah, The Physician Compare site will eventually include data from patient surveys produced by groups like CAHPS that can provide patient experience info to consumers looking for a doctor. You are right that currently the only reviews you see on commercial doctor review websites comes from those who have a beef with the doctor or, once in a while, someone who had stellar care (might even be a relative or the doctor himself!) Medical Quack, Groups representing physicians at the recent CMS town hall meeting on Physician Compare were very adamant that contact info (and of course whether the physician is still alive!)were big concerns they had about this system. That's why they are asking for (and will surely receive) the right to review data about themselves before it goes online. Jim, If you are suggesting that this is a naive and rose-colored glasses way of looking at the move to improve physician quality, then you didn't read what the end result of Physician Compare will be. The idea is that Medicare payments to doctors will be adjusted based on the quality measures used on the site. Empowering patients to make better choices about doctors is "doing something about it" and helps give consumers some important tools so they aren't just assuming their doctor is competent, they will have evidence of that fact.
Harry, Thanks for the catch--noted and changed. I was getting tired last night... Naomi
Joe Says, Are you mistaking me for Naomi Watts? Im flattered but my last name is Freundlich...
Joe Says, In a recent meta-analysis in the June 28 issue of Archives of Internal Medicine, researchers found that statins offered no decreased risk of death in people who were at high-risk of heart disease but did not have established coronary heart disease. They did lower the mortality among men who had established heart disease--i.e. had a previous heart attack. So for the vast majority of people who would be taking a statin with their cheeseburger, the protective effects would be nil. Naomi
NG,doc, Panacea I think you are right that our society (or more accurately, big pharma) has been pushing the message that prescription drugs are preferable to lifestyle changes. The fact that teens abuse Rx drugs may well be related to this attitude we currently have that they are a panacea to all life's problems--and safe to experiment with. Hannah, Thanks for your comment; I appreciate your outrage. As you point out there are other significant problems with eating fast food on a regular basis--high salt intake, empty calories and even environmental considerations.
Jim, I'm not sure who you are accusing of picking "an unneeded and divisive fight." I think if AGs were really out to protect public health they wouldn't be mounting what some call "frivolous" lawsuits against health reform. This is unneeded and divisive--and offers no solution to the problem of insuring 30 million-plus Americans. We have a serious health care crisis in this country that has been heightened by partisan fighting. If attorneys general really had the concerns of their state citizens in mind, they would not try to obstruct this legislation.
Pat S., Barry I can't comment on the wisdom of federalizing Medicaid--in theory it makes a lot of sense and would certainly add equality to a seriously disparate system. Through health reform, there will be an expansion of the number of people who will qualify for benefits as some states that had met only the bare minimum (only pregnant women and children under 6 at 133% of poverty, for example)will have to offer benefits to others. Some studies have found that currently, some 60% of the poor do not even qualify for Medicaid benefits. As to the situation that Barry describes in NYC, the main reason workers like nannies, house cleaners, construction workers and those with similar jobs want to be paid in cash, is that they are often here illegally. That means they are not "gaming" the system to apply for Medicaid--they are routinely uninsured. I have never heard of a middle-class or wealthy person (paid solely in cash)who receives Medicaid. The cumbersome and frequent renewal process (including face to face interviews in some cases), the terrible choice of caregivers and other hardships suffered by those on Medicaid does not makes this a benefit many covet. Naomi
Toggle Commented Sep 7, 2010 on A Longer-Term Fix For Medicaid? at Health Beat