healthsignals new york

Well, at least they asked ...

Evidently, after delays and some frustration, Tennessee's Medicaid information system has gone online.

Here's the line I like best:

Two years ago the General Assembly, frustrated after years of being told TennCare couldn’t provide information lawmakers requested because it didn’t have the computer capability, ordered that the new system be put into place by Dec. 31, 2003.

We have the systems capability in New York, but either the Legislature doesn't ask or, more likely, doesn't insist.

Don't like your insurer? Start a web site

About ten days ago, I got an e-mail asking that I cover this story about Kaiser. Indeed, it asked me why I wasn't covering it. Turns out that there are some who are disgruntled.

Well, mostly we cover national, Northeast, and New York issues here and the Oakland paper is not one I read at all, much less regularly.

So I sent a note to Matthew, who does cover the California market and asked him what's up and whose judgement I respect.? Turns out he got the same e-mail. Here's his posting as a response. On the substance of the issue, I'll defer to him.

Both Matthew and I thought this was an interesting approach to getting the word out. I rather like it. It's not spam and not from the usual sources. Suggested stories and links are welcome, but always subject to scrutiny.

Medicare RX cards' slow expansion

From Daniel B. Moskowitz by way of Medscape ...

The response of seniors to the Medicare-endorsed private prescription drug discount cards so far has been less than enthusiastic. When the card program went into operation June 1, just under 2.9 million seniors had cards in hand—far below the 7.3 million that the Bush Administration had suggested would be enrolled.

"It's been a very slow uptake," said Tim Dickman, chief executive officer, Prime Therapeutics. AARP, for example, sent out 26,000 enrollment kits to members and had only 400 sign-ups by June 1 ...

There's even less support for the discount cards than the raw numbers suggest. Only about 500,000 of the 2.9 million actually signed up for a card. The rest were issued cards automatically by the Medicare managed care plans in which they were already enrolled.

The Bush Administration seems to have abandoned its 7.3 million cardholder projection. Mark McClellan, head of the Centers for Medicare & Medicaid Services (CMS), now talks in terms of "hundreds of thousands" more enrollees. To reach that goal, CMS is looking to follow the lead of private Medicare HMOs and rely on automatic enrollment to boost the numbers. In a June 8 testimony, McClellan told the Senate Finance Committee that he expects to get 400,000 more cardholders through automatic enrollment of seniors already participating in state drug-purchasing assistance programs in Maine, Massachusetts, Connecticut, New York, New Jersey, Pennsylvania, and Michigan.

"Less than enthusiastic"? (2/9/7.3) "Very slow uptake"? (400/23,000)

Wow, what terrible results! If this were a private sector rollout, it would be heads that were rolling. Are these the folks who want to run government like a business? Or is this just how they run businesses?

This month's Medicaid Google

As political exposure indicator, toward the end of each month, we do a Google search on "New York, county, share, Medicaid, property tax."

Last month, the numbers were down to 20,200.

This month, we bumped up significantly to 22,300, probably due to end of Legislative session news coverage and county budget making (and Medicaid blaming). Hey, it's the end of August. What else couild it be?

Numbers of uninsured (and insured) grow

Both insured and uninsured grew, but the uninsured grew faster ...

Last week's health insurance news was a jump in the number of uninsured from 2002 to 2003. Perhaps (undoubtedly?) due to Presidential campaign politics, it got a lot of coverage.

Both the number and percentage of the uninsured increased. An estimated 15.6 percent of the population was uninsured up from 15.2 percent. This equated to 45.0 million people, up from 43.6 million people in 2002.

The number of people with health insurance coverage increased by 1.0 million in 2003, to 243.3 million (84.4 percent of the population).

The percentage and number of people covered by employment-based health insurance fell between 2002 and 2003, from 61.3 percent and 175.3 million to 60.4 percent and 174.0 million. Thus, absent expanded government programs, the numbers would have been worse. The percentage and number of people covered by government health insurance programs increased between 2002 and 2003, from 25.7 percent and 73.6 million to 26.6 percent and 76.8 million, driven by increases in the percentage and number of people covered by Medicaid (from 11.6 percent and 33.2 million to 12.4 percent and 35.6 million) and Medicare (from 13.4 percent and 38.4 million to 13.7 percent and 39.5 million).

You can find the state-by-state figures here. New York showed 2.866 million uninsured or 15.1 percent of its population. Four states showed more than 20 percent uninsured. They were Louisiana (20.6%), New Mexico (22.1%), Oklahoma (20.4%), and Texas (24.6%). Texas has consistently had the highest percentage for some years. Minnesota had the lowest percent (8.7%) and Vermont had the second lowest (9.5%). There were a couple of states in the 10-12 percent range, but no others lower than 10 percent.

Here's the link to the Census Bureau's press conference which also covered the increase in the number of Americans living in poverty.

Here's Krugman's recent op-ed in the New York Times. He ties our current economic sluggishness to this issue by saying that:

...rising health care costs aren't just causing a rapid rise in the ranks of the uninsured (confirmed by yesterday's Census Bureau report); they're also, because of their link to employment, a major reason why this economic recovery has generated fewer jobs than any previous economic expansion.

I think he's right about that, but then he gives us the either/or propositions of the Bush and Kerry camps.

The Bush version is health costs are too high because people have too much insurance and purchase too much medical care.

What we need, then, are policies, like tax-advantaged health savings accounts tied to plans with high deductibles, that induce people to pay more of their medical expenses out of pocket. (Cynics would say that this is just a rationale for yet another tax shelter for the wealthy, but the economists who wrote the report are probably sincere.) Click here for more on the Bush perspective.

The Kerry version is:

health costs are too high because private insurance companies have excessive overhead, mainly because they are trying to avoid covering high-risk patients. What we need, according to this view, is for the government to assume more of the risk, for example by picking up catastrophic health costs, thereby reducing the incentive for socially wasteful spending, and making employment-based insurance easier to get. Click here for a post on one of Kerry's proposals.

Krugman then says:

A smart economist can come up with theoretical justifications for either argument. The evidence suggests, however, that the Kerry position is much closer to the truth.

And he then offers a Canadian-style "single-payer" system as the most credible solution.

I see two problems with Krugman's analysis. First, it's couched as either/or without the possibility of both sides being right. Second, (outside of his taking the word of others that a "single-payer" system is not politically feasible) his only analytical framework is economics. That's not enough. One does not have to reject the possibility of universal coverage to recognize organizational and other problems with single-payer solutions.

With both sides locked into their largely ideological and political positions and employing their own economists, there's one thing we can be confident of. It's going to get worse while the political flailing continues.

Health insurance affects employment

Well of course health insurance costs depress employment ...

No one's surprised are they? Well, I suppose, it's good that the message gets pounded in.

When it's not a system problem

I strongly suspect that most quality problems and most errors are the result of system or structural problems and require system re-configuration and process change to reduce and avoid. And I recognize that sometimes, even when a system is well structured, running smoothly and there are no errors, fate intervenes and the result is unfortunate. That's simply the laws of probability at work.

But sometimes, I'm not so sure that any of the above applies to a particular case or a particular practitioner. Let's face it. Sometimes, people know their stuff, but just can't apply it consistently correctly in the real world, especially under stress. This was the case when I read recently a news account of a physician whose license was suspended for "incompetence and negligence" by New York's Office of Professional Medical Conduct, initially for three years. The suspension was then reduced to three months with the proviso that he complete 125 hours of CME. This particular physician had failed to diagnose an ectopic pregnancy, had wrongly prescribed a drug for a patient "potentially deadly" in combination with another drug another the patient was taking, and had made other errors with other patients.

When I read about this case I thought back to a co-pilot I flew with on just one mission to Europe and the Middle East when I was in the Air Force. This particular co-pilot (we'll call him "Ted") was very experienced. He had lots of flight hours and was technically ready to upgrade to Aircraft Commander. He was quite smart, had graduated from a prestigious technical university, and knew the technical details of the plane we flew. But, sometimes, Ted just didn't seem to be fully present. First, when it was his turn to fly, he seemed sloppy and "disengaged." Then while I was flying into a short field in terrible weather, Ted failed to perform one of the most elemental checks he was responsible for during landing. And when I challenged him on it, he didn't seem to be particularly bothered. I finally lost it when we were just short of departing Turkey for the Middle East, an area politically sensitive even then. Despite the fact that I had reminded the entire crew at least three times, Ted didn't have the proper personal paperwork, and again didn't seem to be particularly concerned about it. Then he told me that he'd known that he didn't have it when we left the US and hadn't bothered to tell me even when I'd raised the issue.

Fortunately, I had a second co-pilot. So I left Ted in Turkey, telling him to find his own way back home and the rest of us continued with our mission. Yes, I threw him off the crew. I later learned that some of the crew celebrated because they already thought Ted was unsafe.

On the way home, I re-read, start-to-finish, Ted's complete flying record. The eight hours over the Atlantic gave me the opportunity to see the patterns that neither I nor anyone else had seen before. Before, it was just isolated incidents. Afterwards, we could see the pattern. Ted was incompetent. He wasn't a bad guy. His book learning was above average. But he just couldn't put it together in the real world in a consistent and safe manner. And no amount of re-training was going to solve the problem. I was greeted by the Squadron Commander and the head of Standarization and Evaluation (quality control) when I returned to the US. Needless to say, they wanted to know why I had tossed a crewmember off my crew. My response was to ask them to read Ted's flying record as I had. The next day, the head of Standardization called to tell me that, having read the record, they didn't need any more information from me. Ted never did become an Aircraft Commander.

This brings me back to where I started. Just as in all fields, some doctors are incompetent. I believe their percentages are much lower than in other fields, but I have no doubt that they're out there. And the solution isn't to suspend their licenses for three months because while they may know more at the end of that time, their ability to apply it will not have improved. A three month suspension strikes me as a political solution, but ultimately inadequate. Ted should never have become responsible for the lives of others. The same is true of some physicians. It's painful; it's unfortunate, even sad. But sometimes, it's just necessary.

Alternatives to evidence based medicine

Heard this a couple years ago, but it's still worth a laugh.

Brailer on health care's information future

This past week I was fortunate to sit in on a conference call that Don Berwick, MD ran with David Brailer, MD, PhD, the National Health Information Technology Coordinator appointed this past April. Berwick sponsored the call for some of the Institute for Healthcare Improvement's program participants.

Brailer summarized the first report his group has put out, the Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care. (PDF)

Here's the essence:

One. Brailer's vision centers on the key consumers, patients and clinicians. The system should be portable and should enable choice. It should: enable access to geograpically distant specialists, improved management, a better functioning market, dealing with fragmentation and misaligned incentives. There was a heavy emphasis on longitudinal information (i.e., following the patient over time) both here and throughout his discussion.

Two. How are we going to make this happen. Brailer emphasizes standard setting a lot, but here he also discussed what he called a "sleeper," the amount of money the Federal government already spends on health care information technology. He estimates that it's about $1.7 billion. That's a lot of leverage. (Think about it, if the Federal government said we expect all those who care for active duty military personnel, their families, veterans, and Federal employees to use systems that met certain standards ...)

Three. Goals include:

a. Informing clinical practice, i.e., bring information and information tools to the professional rather than to the site or institution (Brailer's emphasis). This includes providing access to every MD. It also includes establishing incentives for adoption, including grants, contracts, loans, changes in the Stark anti-kickback rules, pay for use (think of IT as just another clinical technology), and pay for performance.

He also discussed reducing the risk of failed system implementations (more on that later) and promoting use in rural and underserved areas.

b. Inter-connecting physicians. If we deploy IT, but still provide care in "silos," we will have lost a substantial opportunity. The most important lost opportunity is, again, following the patient longitudinally. He also discussed -- and emphasized regional collaboratives and the need to start in more than one or two systems. Systems should be "somewhat standardized" and not just the result of organic growth. There must be interoperability between systems.

c. Personalizing care. Brailer mentioned that this was the third goal in sequence, not priority. A personal health record should enhance personal choice, provide performance information, enable the use of telehealth services.

d. Improve population health. This includes public health surveillance, quality and health statistical monitoring, and support of clinical trials and research. He believes that the time for drug trials can be reduced by years.

Brailer expects this work to take five to ten years, which sounds about right. They are now working on establishing priorities and should have something out next month.

Brailer makes a lot of sense and this is where the Federal government is going now. My guess is that even if Kerry replaces Bush, there won't be much fundamental change in the direction of Federal policy. At the most macro level, this whole area is one of the few "win-win" areas of policy these days. So government officials of all stripes are looking to get on the bandwagon.

Of course, New York is going nowhere near the same direction. Instead New York is reinforcing all of its old dysfunctions most notably having hospital "silos" as the center, if not the only part of the system. While Brailer talks about regional collaboratives and getting clinical information to clinicians, we in New York talk about sending money to individual hospitals with no requirements that they interact with anyone outside their walls.

Medicare RX benefit and the election

Two-thirds of those on Medicare don't think that the Medicare Pharmaceutical benefit will help them personally. Nearly one half have an unfavorable impression of the new law versus about one-quarter with a favorable impression. Here's the study done by Kaiser Family Foundation and Harvard School of Public Health (PDF).

Twenty-eight percent said that the passage of the Medicare law will have an effect on their vote for president. Of those, Kerry is more likely to benefit than Bush by an over two to one ratio.

This is surprising, right?