Health Law

Health Wonk Review: Samhain edition

By David Harlow

All Hallow's Eve (celebrated around these parts tomorrow night) incorporates traditions tied to the earlier Celtic holiday of Samhain, which marks the beginning of winter -- as the great (swing) state (or should I say Commonwealth) of Pennsylvania knows only too well. 

As we enter the last lap of the interminable presidential campaign of 2008, with one eye on our 401(k)s and HSAs, keep these Samhain traditions in mind:  This is a time of renewal, lighting new fires, divination, and the day to go down to a "boundary stream," take three stones from the water with your eyes closed, put them under your pillow, "ask for a dream that will give you guidance or a solution to a problem, and the stones will bring it for you."  If you don't have a boundary stream handy, print out three copies of this post.  The wisdom of the crowds (or at least of the ragtag band of bloggers whose health wonkery is reviewed here today) may offer you that sort of guidance, though I'm fairly confident that it will not put you to sleep.

Why we do the things we do

No divination required here: for most rational economic actors, the why has a lot to do with the wherewithal.  Folks want to keep the home fires burning -- and that takes some cold hard cash.  

Also, as a species, we seem to be fascinated by shiny objects.  Take these two factors together, add a dose of separation of roles of health care consumer and health care payor, and the table is set for overconsumption of new (and often unproven) health care services (some of which involve office-based shiny objects), to the financial benefit of the provider. 

For a good treatment of the recently issued report from the Center for Studying Health System Change (with support from RWJF) titled ?High and Rising Health Care Costs: Demystifying Health Care Spending,? see Maggie Mahar's discussion of the many observations synthesized by Paul Ginsburg at Health Beat.  The gestalt here is not new, but clearly identifying and quantifying the ways in which our dysfunctional health care system promotes the utilization of new therapies should prove instructive for the new health care policy cadres about to descent on the Potomac (now there's a boundary stream for you).  Maggie quotes Don Berwick, who has written about our oversupply of health care resources -- warms the cockles of my former-CON-regulator heart -- in her discussion.  (By the way, for all you Don Berwick fans out there: I will be posting my recent interview with him in a day or so, so be sure to check back.)

Daniel Goldberg, writing at the superbly-designed Medical Humanities Blog picks up on this thread and highlights the applicability of the McKeown thesis (hey, you all know what that is, right?) to this discussion.  In brief, McKeown's thesis is that medicine isn't necessarily all it's cracked up to be -- 17th-to 20th-century improvements in population health measures likely had more to do with social and economic changes (e.g., improvements in the standard of living) than with public health and medicine (e.g., drugs and shiny objects). 

At Colorado Health Insurance Insider, Louise Norris focuses on this report, too, and takes issue with Maggie's statement that the federales should be doing a better job of negotiating proces, given their market power, noting that in at least some cases they have done so.  

The almighty dollar

David Hamilton, blogging at BNET's Health Care Industry, tells us that trouble with Mammon drives for-profit HMOs to drive up Medicare Advantage premiums.  (Hey, they're for-profit companies.)  This is related to the brouhaha over brokers' fees on Medicare Advantage policy sales -- see the WSJ Health Blog for more on that story (including a link to a hortatory letter from Pete Stark to CMS).

David Williams reminds us that it takes two to tango -- pharma companies can't pay outlandish "consulting" fees to physicians unless physicians take them -- and his Health Business Blog tells us of GlaxoSmithKline's new policy limiting such payments and requiring public disclosure of payments.

Ontario's provincial government just inked a deal with the physicians' union cutting physician pay.  The union may be splintering (some members smell a sellout).  Shades of Sustainable Growth Rate rules and overrides.  A tip of the hat to Sam Solomon at Canadian Medicine.

These three posts raise (yet again . . . ) the question of whether health care delivery and financing systems need serious reform in order to unskew the incentives and ensure that expenses are held in check.

There's no place like home

A medical home, that is.  The question of the moment is whether the medical home is the flavor of the month or something more.  Much has been written in recent weeks about the implementation of the medical home model by Geisinger.  (The HealthBlawger thinks the medical home is something of a new spin on the good old PCP or family doctor back home in Kansas.)  I wrote about Geisinger's success with the medical home model and observed that what they've got that others ain't got is (not courage, but) PCPs.  Can't have a medical home without PCPs. 

Joanne Kenen, of New Health Dialogue, interviewed Geisinger CEO Glenn Steele, who presents the medical home initiative as one of a series of experiments.  John Iglehart, writing at Health Affairs, calls for further development of the medical home model in response to the WHO's call for increased efforts in the primary care arena worldwide.  

We'll always have "Decision '08"

Come next Wednesday, there will be no more comparisons of presidential candidates' health care reform plans.  Really.  But no worries, don't hyperventilate -- we'll wean you off slowly, starting with the Brain Blogger's two health care and politics wrapups: one each for the Red and the Blue.

For last licks on the McCain health care reform plan, we turn first to Jason Shafrin, the Healthcare Economist, who takes a look at how much that McCain policy would actually cost a person after the tax credit.  Anthony Wright joins the fun at Health Access, picking up on the McCain camp's October surprise.  And finally, Bob Laszewski, at Healthcare Policy and Marketplace Review, laments that -- win or lose -- McCain's proposed replacement of employer-based health care insurance with a personal responsibility model is likely on the outs.

Is it the Economy, Stupid?

The fires in the engines of our economy seem to be taking an early break for Samhain, and a number of bloggers have been wrestling with the implications.  At Health Care Renewal, Roy Poses castigates Ascension Health for its cut and run maneuver in Detroit, closing an inner city hospital while building a new suburban facility.  Adam Fein looks at some historical data at Drug Channels and posits that the economy's nosedive will not bring on a reduction in drugstore sales.

Brian Klepper spoke at the recent Health 2.0 conference in San Francisco about Health 2.0 amid the economic downturn, and posted a version of those remarks at The Health Care Blog.  Given the belt-tightening, Brian sees Health 2.0 tools as a welcome means to help squeeze the waste out of the system.  (The HealthBlawger didn't make it out there, but did attend the Health 2.0 Northeast get-together earlier this month.) 

At Workers' Comp Insider, you may follow Jon Coppelman through the looking-glass as he reviews the implications of the financial crisis for workers' comp.

Annie, blogging at Home of the Brave, wonders why nurses and nursing aren't a bigger part of the discussion on health care reform, given their work in the front lines.

And finally, InsureBlog's Hank Stern has a "duh" moment followed by an "aha" moment (it must be that Samhain-season sense of renewal . . . ) when reading that targeted social services for a homeless population can reduce emergency department and other hospital utilization for "frequent fliers" by nearly two thirds. 

Evidence-based medicine: An analogy too far?

Jaan Sidorov, at Disease Management Care Blog really let Billy Beane, John Kerry and Newt Gingrich's baseball analogies (in a NY Times op-ed piece on evidence-based medicine) get under his skin.  "Health care is different" he says, and of course it is.  (I can only take a few minutes of baseball announcer balderdash on hyper-obscure and often meaningless statistics, but Lord knows I can drone on about health care ad infinitum.) 

Clearly, though, Jaan would not throw out the evidence-based baby with the baseball bathwater.  There are metrics that are useful (and probably a dozen times as many that are not particularly useful) in health care.  The challenge is in discerning the wheat from the chaff. 

I understand, by the way, that NQF has been culling through its vast repository of measures in order to identify the really predictive ones.  Stay tuned for an announcement on that front within a few weeks. 

Well, if you had been paying attention to the emanations from your three river stones, you would have realized that this brings you to the end of the final pre-election edition of Health Wonk Review. 

See you on the other side.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Full post as published by HealthBlawg on October 30, 2008 (boomark / email).