Article on the health system and reform from a doc living in NC in yesterday's News and Observer.
Article from Newsweek, suggesting that deficit spending and not talking about the choices necessary to have a long term balanced budget (only had 4 in the past 49 years) is the one truly bipartisan issue (meaning neither party is honest about it).
From the NY Times, a hospital suggesting a couple divorce due to the onset of Alzheimer's disease, and the effect of the disease on long term care costs.
Op-ed from one of the WaPo editorial writers reprinted in the News and Observer discussing the very divergent views folks have about Ted Kennedy. This is mostly interesting because it points out the strong differences that people have of all sorts of things and people....makes it seem like we live on different planets at times.
Not so much posting this week....beginning of the semester and life intervening....back up to speed after Labor Day.
Monday, August 31, 2009
Friday, August 28, 2009
Ted Kennedy, Cancer and are there any limits?
I have seen several places where folks ask would Ted Kennedy have gotten the same care had he had a 'public option'? I think the answer is most likely yes.
He was a federal employee. He had the federal employees health plan, which provides a series of insurance choices to employees. When you read about various reform plans setting up health insurance exchanges and the like in states whereby people can purchase plans, they are mostly based on the idea of the federal employees health plan (again, lots of options, individuals choosing what they want, and having different premiums, deductibles and the like based on their choice). The federal gov't paid premiums on behalf of Sen. Kennedy and he paid premiums as well. I don't know which plan he chose.
Since he was over 65, Medicare was a secondary payer of all of his care. If he retired, then Medicare would become the primary payer of his health insurance, and he could elect retiree Medigap insurance from the federal gov't. Medicare is a huge, federal insurance program that is primarily tax financed and covers about 45 Million Americans. It provides the best evidence of what a public option might cover, how it would work. And the answer is it covers just about anything that is not experimental. So, the short answer to the question, 'would Ted Kennedy have gotten the same care if he had a public option?' is most likely yes. I say most likely because I don't know exactly what he got. If he got something that was experimental, neither Medicare nor any private insurance company would have likely paid for it. Such care is typically received via a research study or must be paid for out of pocket.
You have a far greater chance of being denied care by a private insurance company than you do by Medicare. That is part of why Medicare is going broke and insurance companies are very profitable!
Here is a straightforward discussion of Sen. Kennedy's care, and the reality of certain types of cancer diagnoses, about 40 years after President Nixon declared the War on Cancer. There are discussions of costs, benefits, perspectives of fighting, American culture and the like. Here is an interesting discussion of progress against cancer. Most interestingly, is the distinction between increased survival after detection of cancer (that has occurred) and the relatively limited success in curing cancer, and causing/allowing someone to die of something else. Meaning for many cancer diagnoses but not all, treatments forestall death for different periods of time and improve quality of life as well. But, the notion of 'War on Cancer' implies defeat of an enemy, and that is not very likely. It doesn't mean increased research and treatment hasn't been worth it, just that the metaphor doesn't match the reality of cancer. And of course if cancer were eradicated, there would be an explosion in heart disease mortality, because the mortality rate of being born, is of course, 100%.
The health reform discussion has been mostly heat and no light on these basic questions:
(1) Are there limits to what should be done in terms of medicine/health care?
(2) Do we actually now provide treatments for which the costs are greater than the benefits?
(3) How much are benefits worth....is any incremental benefit worth any cost?
(4) If yes is the answer to question 3, how will we pay for it? What else will we forego?**
(5) If no is the answer to question 3, how do we practically work out the principle that there are limits....the principle has to be operationalized to actual care provision?
(6) How do we address all of these questions (there are many related questions and controvseries) in an American way, meaning in a way that works for our culture?
We really need some grown up discussion.
**The federal budget in 2009: Social Security (22%); Military (20%); Medicare 14%; Interest on the debt (8%); Medicaid (7%). Everything else 29%.
He was a federal employee. He had the federal employees health plan, which provides a series of insurance choices to employees. When you read about various reform plans setting up health insurance exchanges and the like in states whereby people can purchase plans, they are mostly based on the idea of the federal employees health plan (again, lots of options, individuals choosing what they want, and having different premiums, deductibles and the like based on their choice). The federal gov't paid premiums on behalf of Sen. Kennedy and he paid premiums as well. I don't know which plan he chose.
Since he was over 65, Medicare was a secondary payer of all of his care. If he retired, then Medicare would become the primary payer of his health insurance, and he could elect retiree Medigap insurance from the federal gov't. Medicare is a huge, federal insurance program that is primarily tax financed and covers about 45 Million Americans. It provides the best evidence of what a public option might cover, how it would work. And the answer is it covers just about anything that is not experimental. So, the short answer to the question, 'would Ted Kennedy have gotten the same care if he had a public option?' is most likely yes. I say most likely because I don't know exactly what he got. If he got something that was experimental, neither Medicare nor any private insurance company would have likely paid for it. Such care is typically received via a research study or must be paid for out of pocket.
You have a far greater chance of being denied care by a private insurance company than you do by Medicare. That is part of why Medicare is going broke and insurance companies are very profitable!
Here is a straightforward discussion of Sen. Kennedy's care, and the reality of certain types of cancer diagnoses, about 40 years after President Nixon declared the War on Cancer. There are discussions of costs, benefits, perspectives of fighting, American culture and the like. Here is an interesting discussion of progress against cancer. Most interestingly, is the distinction between increased survival after detection of cancer (that has occurred) and the relatively limited success in curing cancer, and causing/allowing someone to die of something else. Meaning for many cancer diagnoses but not all, treatments forestall death for different periods of time and improve quality of life as well. But, the notion of 'War on Cancer' implies defeat of an enemy, and that is not very likely. It doesn't mean increased research and treatment hasn't been worth it, just that the metaphor doesn't match the reality of cancer. And of course if cancer were eradicated, there would be an explosion in heart disease mortality, because the mortality rate of being born, is of course, 100%.
The health reform discussion has been mostly heat and no light on these basic questions:
(1) Are there limits to what should be done in terms of medicine/health care?
(2) Do we actually now provide treatments for which the costs are greater than the benefits?
(3) How much are benefits worth....is any incremental benefit worth any cost?
(4) If yes is the answer to question 3, how will we pay for it? What else will we forego?**
(5) If no is the answer to question 3, how do we practically work out the principle that there are limits....the principle has to be operationalized to actual care provision?
(6) How do we address all of these questions (there are many related questions and controvseries) in an American way, meaning in a way that works for our culture?
We really need some grown up discussion.
**The federal budget in 2009: Social Security (22%); Military (20%); Medicare 14%; Interest on the debt (8%); Medicaid (7%). Everything else 29%.
No column in News and Observer today
I am taking this week and next week off, but my column in the News and Observer on health reform will start back on Sept. 11. I will still be blogging in the meantime.
Wednesday, August 26, 2009
Private insurance, competition and who pays
This is a very interesting post with many links, discussing the limits of the competition among insurers to hold down costs in a system in which so many people get employer provided health insurance. The argument goes like this: On the one hand, employers are not great purchasers/arrangers of health insurance because employees pay for insurance costs via lower wages, so employers aren't incentivized to try harder. On the other hand, because premiums paid by employers on behalf of their employees are excluded from taxation, this means that workers do not face the true costs of their insurance.
This means that neither of the purchasers (employers or employees) are properly incentivized to try and hold down costs.
This means that neither of the purchasers (employers or employees) are properly incentivized to try and hold down costs.
More on what if the umpire is wrong
Jon Gabel writes an op-ed in the NY Times, noting that the CBO has historically been too conservative in estimating savings due to Medicare policy changes.
I have written about the issue of scoring, mainly because of a private scoring group that claims they out-predicted CBO on the issue of uptake of high deductible plans earlier this decade.
Here is a post criticizing HSI, the private scoring firm that has academics that were supporters of Sen. McCain's presidential bid. Steve Parente responds in the comments, and he is correct that he and Roger Feldman and others working with this group are proper academics who have much peer reviewed research, that is linked off their web site (all contained in the issue of scoring link above). I should also say when I have called Steve Parente to ask him some questions about his model he responded and discussed them in a very transparent and helpful way, as I would expect a professor to do for another professor.
Also, for those of you watching the NC Public TV call in show last night, when Sen. Burr said his plan (Patients' Choice Act, past links where I have written about PCA here and here and here and here and here ) would insure 34 Million persons, he is using HSIs private score. As far as I can tell, the PCA has still not been scored by CBO, which means the sponsors haven't given the necessary information to CBO to do so. To put the 34 Million that Sen. Burr claims in perspective, HSI's private score says Senate HELP bill will move to nearly universal coverage....so CBOs scores are consistently showing less effect on insurance increases (and therefore cost of bills) than is HSIs.
Sen. Burr really needs to have to the PCA scored by CBO so comparisons amongst bills can be apples to apples.
UPDATE, 11:10am, 8/26/09: Someone in Sen. Burr's office that would know the details told me that they want PCA to be scored but that CBO is back-logged and that is why it hasn't been scored yet. The Patients' Choice Act was introduced in May, 2009....but I will take this person at their word that the scoring delay is due to CBO workload.
I have written about the issue of scoring, mainly because of a private scoring group that claims they out-predicted CBO on the issue of uptake of high deductible plans earlier this decade.
Here is a post criticizing HSI, the private scoring firm that has academics that were supporters of Sen. McCain's presidential bid. Steve Parente responds in the comments, and he is correct that he and Roger Feldman and others working with this group are proper academics who have much peer reviewed research, that is linked off their web site (all contained in the issue of scoring link above). I should also say when I have called Steve Parente to ask him some questions about his model he responded and discussed them in a very transparent and helpful way, as I would expect a professor to do for another professor.
Also, for those of you watching the NC Public TV call in show last night, when Sen. Burr said his plan (Patients' Choice Act, past links where I have written about PCA here and here and here and here and here ) would insure 34 Million persons, he is using HSIs private score. As far as I can tell, the PCA has still not been scored by CBO, which means the sponsors haven't given the necessary information to CBO to do so. To put the 34 Million that Sen. Burr claims in perspective, HSI's private score says Senate HELP bill will move to nearly universal coverage....so CBOs scores are consistently showing less effect on insurance increases (and therefore cost of bills) than is HSIs.
Sen. Burr really needs to have to the PCA scored by CBO so comparisons amongst bills can be apples to apples.
UPDATE, 11:10am, 8/26/09: Someone in Sen. Burr's office that would know the details told me that they want PCA to be scored but that CBO is back-logged and that is why it hasn't been scored yet. The Patients' Choice Act was introduced in May, 2009....but I will take this person at their word that the scoring delay is due to CBO workload.
Smoking deaths worldwide
Interesting new study from the American Cancer Society estimating that around 1 billion people smoke worldwide; around 35% in high income/developed nations like the USA and around 50% in low income/developing nations. Actually, the USA now has one of the lowest smoking prevalence rates of high income nations at about 23-24% of adults (it was around 55% in 1950). However, the rate of decrease has slowed quite a bit. It went from 55% in 1950 to around 25-26% in 1990, and now down to 23-24% almost 20 years later. This suggests we might be approaching the background rate of smoking, or the rate below which it will be quite hard to go below. Canada's smoking prevalence is a bit lower than ours, but most of continental Europe and certainly Japan, where smoking rates are over 40% has much higher smoking prevalence.
There are lots of factoids about China highlighted. For example, ~60% of Chinese men smoke, and China consumes 37% of the world's cigarettes. This is part of the reason the smoking settlement went through so quickly. The tobacco companies were trying to fix and make predictable their costs in the USA, and then focus on selling cigarettes in other nations.
I co-authored a book with several colleagues from Duke called, The Price of Smoking, published by MIT Press in 2004. We estimated that in $2000 dollars, the true societal cost of a pack of cigarettes was $40, with costs distributed as follows:
*The smoker bears about $33/pack, mostly through shortened life.
*The family of the smoker bears around $5.50/pack via things like second hand smoke.
*The rest of society (external costs) are about $1.50/pack.
We didn't estimate intangible costs. For example, my wife's father died at age 64 of lung cancer, and had COPD and was a life long smoker. He died before my youngest child was born, which my wife would say is costly (she wouldn't use the word costly, but stick with me). We assigned value of $0 to such costs, basically because we didn't know how to estimate such costs in dollar terms. If you would like to monetize such costs, just add zeros....
There are lots of factoids about China highlighted. For example, ~60% of Chinese men smoke, and China consumes 37% of the world's cigarettes. This is part of the reason the smoking settlement went through so quickly. The tobacco companies were trying to fix and make predictable their costs in the USA, and then focus on selling cigarettes in other nations.
I co-authored a book with several colleagues from Duke called, The Price of Smoking, published by MIT Press in 2004. We estimated that in $2000 dollars, the true societal cost of a pack of cigarettes was $40, with costs distributed as follows:
*The smoker bears about $33/pack, mostly through shortened life.
*The family of the smoker bears around $5.50/pack via things like second hand smoke.
*The rest of society (external costs) are about $1.50/pack.
We didn't estimate intangible costs. For example, my wife's father died at age 64 of lung cancer, and had COPD and was a life long smoker. He died before my youngest child was born, which my wife would say is costly (she wouldn't use the word costly, but stick with me). We assigned value of $0 to such costs, basically because we didn't know how to estimate such costs in dollar terms. If you would like to monetize such costs, just add zeros....
Tuesday, August 25, 2009
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