Monday, April 30, 2012

I Like My Funds Extra Slushy

Readers of this blog are aware of my fixation on transparency. Readers of my other blog, Again? Really?, know that I am particularly offended by slush funds, large amounts of taxpayer money redirected by government entities to surreptitiously benefit pet causes or personal gain. The slush finds of a local government might be in the thousands or possibly a million dollars or so. It takes the federal government to create a billion dollar boondoggle.

Insured Americans will be paying a new fee as of October 1, 2012. Anthem Blue Cross sent a warning announcement last week to advise us that they will be adding the charge to our bills. “The Affordable Care Act (PPACA) established the Patient-Centered Outcomes Research Institute (PCORI) to explore the effectiveness, risks, and benefits of medical treatments. This study is also known as Comparative Effectiveness Research (CER). PCORI is a nonprofit, nongovernmental organization supported by a trust fund that is financed in part by fees from health plan insurers.”

The fees are $1 per covered person in the first year. $2 per person in the second year. And after two years? The $2 per person per year will be adjusted for medical inflation.

Bureaucracies, in general, like acronyms, but the combination of acronyms and money make for a government love affair.

Comparative Effectiveness Research came into prominence as part of President Obama’s American Recovery and Reinvestment Act of 2009. $1.1 Billion was allocated.
  • $300 Million for the Agency for Healthcare Research and Quality.
  • $400 Million for the National Institutes of Health.
  • $400 Million for the Office of the Secretary of Health and Human Services.
This wasn’t a beginning, middle and end. This was seed money.

The Department of Health and Human Services (HHS) explained that CER “compares treatments and strategies to improve health. This information is essential for clinicians and patients to decide on the best treatment. It also enables our nation to improve the health of communities and the performance of the health system.”

Gosh that sounds good.

According to the National Cancer Institute, CER has both its proponents and detractors. One key issue was brought up by Jeffrey Kindler, CEO of Pfizer, who wondered whether the results from Comparative Effectiveness studies would be “automatically linked” to insurance coverage decisions. In other words, will healthcare in the future become one size fits almost all and too bad about the rest.

In his paper “Comparative Effectiveness Research and Kindred Delusions”, Norton Hadler, MD expanded on the difference between efficacy and effectiveness.

I have nothing to add to that debate. My only question is “How Much?” How much money, your money in taxes and your money in fees, are we spending on this and who is getting it?

Billions of dollars funneled through the Department of Health and Human Services became even more of an issue last week when the Government Accountability Office (Yes, that GAO) found that the Obama administration was wasting $8.3 Billion on a questionable Medicare program.

As part of a “Demonstration Project”, HHS has created an experimental program to study the effects of money on the insurance market. This experiment is to award bonuses to high quality managed care Medicare policies known as Medicare Advantage. High quality, like intellectual honesty, was one of the first victims of this scheme. To make a long story short, the money, most paid out in the next three years, covers the cuts that were made in these popular programs by the President’s health care law. The PPACA took money away, but Health and Human Services put the money back in through the back door.

The independent Medicare Payment Advisory Commission panned the misdirection. The Republicans think that this looks suspiciously like a re-election driven decision. The New York Post didn’t bury the lead. They labeled it a political slush fund.

What we are talking about is money. We know where it comes from, US. What we don’t know is where it is going and why. Unlimited funds funneled through Kathleen Sebelius and her politicized Department of Health and Human Services are sure to arouse suspicions. Add to this an $8.3 Billion experiment and you have the potential for a real problem.


Monday, April 23, 2012

It Sucks To Be Poor

It sucks to be poor. It is nobody’s goal in life to be poor, to wonder how you are going to feed your family, keep a roof over your head, or to be unable to afford the most basic of needs or wants. I’ve been poor, not homeless or destitute, but close enough to appreciate the fear and uncertainty that comes with an overdrawn back account and a baloney and tater tot dinner.

I’ve never received government assistance, not even unemployment compensation. So I have never had to check in with a government employee, told where I could live, or what groceries I could buy. And when I needed to take my children to the doctor, I’ve always had my choice of all of the pediatricians in town.

The poor have Medicaid.

Medicaid. Fraud ravaged. Doctor hated. Taxpayer resented. Medicaid. And no one likes Medicaid less than the people it was designed to help.

There are 1.7 million Ohioans receiving state funded medical assistance. Ohio is revamping Medicaid, again.

Eleven companies recently participated in a complex bidding process to win a piece of this action. Five won the opportunity to provide coverage. Five lost and are filing appeals. One, Anthem Blue Cross the #1 insurer of Ohioans, shrugged off its loss and walked away.

Medicaid, the State of Ohio’s single payer health care system for the poor, appears to be mired in controversy. As reported in the Columbus Dispatch, there are charges of more than just irregularities, mistakes, and a shocking lack of transparency. There may have been actual fraud and false statements on the applications.

Some of the companies that were shut out contacted London based Barclays to analyze the process. They found “Scoring results indicate considerable inconsistencies among bidders…Scoring processes are always complex, especially in markets this large, but typically not to this degree.”

In a rush to save $1.5 Billion (real or imagined) in the next two years, the state may have selected up to three vendors thanks to applications enhanced with inflated statistics. Though the process was supposed to “improve the coordination of care for 1.7 million recipients and improve health”, it may, instead, have been just one more arbitrarily awarded government contract.

It is one thing to entrust your children’s health to the lowest bidder. It is even worse to be herded to a facility or provider that lacks the integrity to compete fairly. But when you are a football, when you are tossed from one player to another, you don’t have much say in the process.

But then again, it sucks to be poor.


Wednesday, April 11, 2012

The Fixer

Her Nationwide guy suggested that she call me. And though I appreciate Mike’s confidence, I also know that his referrals are often people who have somehow fallen through the cracks of our system. This woman epitomized the permanent flaws in this and any system of health care. And more to my frustration than hers, I could not fix her problem.

Much like Eddie Vedder’s The Fixer, I have always been obsessed with making things right, of solving everyone’s problems. That empathy works well in what I do for a living. But I am deeply frustrated when I encounter a situation that can’t be fixed. Here is hers:

The woman, we’ll call her Maria, has group insurance through her employer. The cost of the policy has increased over the years, but the employer is still paying the vast majority of the premium. This year the employer changed the coverage to a High Deductible Healthcare Plan, in other words, a policy that qualifies for an HSA. Maria no longer has an office visit copay. Maria no longer has an Rx card. All of these expenses are applied towards her $4,000 deductible. In theory, this might save her money. In reality, she is screwed. She is on two very expensive medications. One is $885 for a three month supply. The other is $1,400!

Where does she come up with the money for these prescriptions? She makes just enough per month that she won’t qualify for any help from the drug companies. She makes too little to be able to afford the medications she needs to be able to work.

Got an answer? Neither do I?

No system could possibly sustain the cost of paying for everyone’s doctors’ visits, prescriptions, and hospital stays. We must contribute. We must either pay for insurance or be taxed by the government (or both) to fund the system that pays most of the bills. The balance, whether that structure includes copays or deductibles, must be paid by the person receiving treatment. Should we all be responsible for the same amount? Will there be a sliding scale based on income, location, or family size?

No matter the final outcome, most people will be offended when it is their turn to pay. Worse, many people will be forced to pay more than they feel that they can afford. And some will be buried in debt. The other choice is to simply limit the most expensive care based on survivability and efficacy. And that opens another set of worries.

In a recent Forbes article, Richard Grant argues that what we need is less regulation, not more. “Government’s main role has been to serve as the enforcer of a cartel that limits the supply of doctors, of hospitals, of drugs, and of innovative alternatives.” There is truth to all of that. And if we reversed our course and somehow made it to a completely open market, the well-off and educated, like Mr. Grant, might receive better care for less. Unfortunately, the Maria’s of our world would be collateral damage. I’m not sure which regulations Mr. Grant would like to eliminate. Do we want to trust the marketplace to license doctors and approve prescriptions?

The HSA policy is a half-hearted attempt at empowering the patient and controlling costs. It succeeds at neither. Does Maria need to be on these expensive medications? Would more common, less expensive drugs, be almost as good? Since at least one of these drugs is for a mental condition, would she have the needed faith in a new prescription that was purchased not because her doctor thought it was better for her, but because she can’t afford the good one? The experiment is doomed to failure.

And I can’t help her. And there is no moment worse for a Fixer than when he realizes that there is nothing that he can do.