The Wall Street Journal calls it the “Medicaid Fat Fee,” Time magazine refers to “Arizona’s Flab Tax”  while Arizona’s top health officials say a proposed penalty that would be levied on certain Medicaid recipients “is a way to reward good behavior”—a stick without the carrot approach.

At issue is the latest plan to help Arizona make up for its $1.15 billion budget shortfall and planned 28% cut to the state’s Medicaid program. The idea is to require certain childless adults—those who are obese and fail to follow a doctor-ordered weight-loss plan; those who are chronically ill with a condition like diabetes and don’t adhere to recommended treatment; and smokers—to pay a $50 surcharge.

If instituted, the plan is projected to add about $500 million to fill the budget deficit. It would also signal the first attempt ever to penalize Medicaid recipients for what the state deems “unhealthy behaviors” that drive up health care costs. “If you want to smoke, go for it,” said Monica Coury, spokeswoman for Arizona's Medicaid program. “But understand you're going to have to contribute something for the cost of the care of your smoking.”

Despite support from Gov. Jan Brewer and the GOP-heavy Arizona state legislature, the proposed “fat tax” has its detractors, especially among advocates for the poor. In an interview on Southern California Public Radio (SCPR), Arthur Caplan, Director of the Center for Bioethics at the University of Pennsylvania said of the plan “I don’t think it’s fair, I think it’s a bad idea.” Caplan says singling out the “poorest of the poor,” (in Arizona we’re talking about a family of two earning under $15,000/yr) is “regressive, short-sighted and cruel… It’s just easy to pick on the poor who do stigmatized things.”

Continue reading →

When we dole out blame for rising health care costs the familiar suspects are hospitals, insurers, and profit-hungry drug and device makers. High-priced specialists usually rate a mention as well. But what about primary care physicians? It turns out that through excessive testing, improper prescribing and other types of unnecessary care these “gate-keepers” also contribute to spiraling health care spending. And worse, this excess treatment not only doesn’t help patients, it can actually harm them.

This week the National Physician’s Alliance released the "Top 5" ways primary care physicians like internists, family practitioners and pediatricians can reduce health care costs while also improving the quality of care for their patients. Their recommendations are surprisingly simple and in most cases advise against the overuse of certain tests and therapies. They are recommendations that should be—but often aren’t—considered the standard of care; for example, not ordering EKG’s or cardiac screening for low-risk patients; not prescribing antibiotics for a child’s sore throat until a strep test confirms infection, and not performing x-rays or CT scans on patients who have experienced fewer than six weeks of lower back pain unless “red flags” are present.

Continue reading →

For young women just starting out in a new city and in need of primary reproductive care, Planned Parenthood is a trusted and necessary provider. The same is true for wary teenagers and women of limited financial means all over America who want to be responsible about preventing pregnancy and sexually transmitted diseases but face limited options for care. For mothers, single women, poor women, middle class women and teenagers alike, the 865 Planned Parenthood clinics around the country provide a safe, affordable and easily accessible haven for essential care, including access to contraceptives, preventive services like Pap screening for cervical cancer and testing for sexually transmitted diseases. And although many of these clinics do offer safe abortions; when you include both the surgical and non-surgical kind, abortion makes up just 3 percent of all the services proffered each year by Planned Parenthood.

That 3 percent was enough to convince Governor Mitch Daniels of Indiana (a former hopeful in the upcoming Republican presidential race) to sign into law this month the first bill to eliminate all federal and state Medicaid funding for 28 Planned Parenthood clinics that provide care to 9,300 women covered by Medicaid in in his state. Of course it’s true that the Hyde amendment already prohibits federal support for abortion in Indiana (as it does in all states). And Indiana is one of 33 states that also prohibits state Medicaid funding for the procedure except in the case of rape, incest or life endangerment. So by passing—and already enforcing—a law that denies coverage to poor women using Planned Parenthood, Indiana is not really battling abortion, but instead singling out one of the top providers of women’s health care and effectively blocking access to preventive reproductive care and family planning services.

Continue reading →

At the core of health reform is an increased emphasis on evidence-based medicine; a movement toward reimbursement policies and quality ratings that encourage doctors and hospitals to use the most effective and patient-appropriate treatments, backed by clinical data and scientific studies. But when it comes to interventional cardiology—using devices like balloon angioplasty and stents to open blocked arteries—it seems that evidence is still taking a back seat to deeply ingrained practice patterns.

Case in point: Even though many well-designed clinical studies conclude that drug therapy can reduce the risk of heart attack and death in people with stable coronary artery disease just as well as more expensive invasive procedures, many cardiologists continue to use interventions like propping open blocked arteries with costly stents instead of first trying medication. Besides exposing their patients to unneeded risk, just the inappropriate use of so-called “drug-eluting” stents alone increases Medicare expenditures by $1.57 billion each year.

“We’re still not seeing practice trends that are consistent with people following the evidence,” Peter W. Groeneveld, assistant professor of medicine at the University of Pennsylvania School of Medicine tells me. In fact, he continues, it seems that cardiologists are actually “resolutely ignoring the evidence” in favor of performing interventions that they seem to believe are better. Or, as the Los Angeles Times put it recently; “You can lead a cardiologist to water but, apparently, you cannot make him drink.” 

Continue reading →

The part of the Ryan budget proposal calling for an overhaul of Medicare—turning it into a voucher program for seniors to buy private insurance—did not go over well with many Americans. In fact, the outcry from seniors from both political parties was great enough that the House leadership has backed away from their insistence that raising the budget debt limit be dependent on revamping Medicare. But what about Medicaid?

So far, the GOP has not backed down from their plan to “reform” the federal-state program that provides benefits to some 69.5 million poor children and adults as well as the disabled and frail elderly in nursing homes. The Ryan budget proposal calls for cutting federal funding for Medicaid and turning it into a block grant program. It also includes the GOP’s repeal of the Patient Protection and Affordable Care Act which would effectively deep-six the health law’s planned expansion of Medicaid. Together, these provisions would result in federal savings of $1.4 trillion over the 2012 to 2022 period, according to the Congressional Budget Office. Yet the agency concluded that although “states would have additional flexibility to design and manage their Medicaid programs and might achieve greater efficiencies in the delivery of care than they do under current law” they would also be required to reduce enrollment rolls, cut provider reimbursement, slash benefits and increase cost-sharing.

Continue reading →

Less than a year after Congress passed the Patient Protection and Affordable Care Act, a newly conservative House voted to repeal it. Aware that such a repeal was purely symbolic and would be blocked by the Senate and vetoed by President Obama, GOP leaders instead promised “death by a million cuts” and have introduced a steady series of bills that de-fund many of the health law’s provisions.

For the GOP, this goal of de-funding the health reform law has been increasingly intertwined with efforts to cut the federal deficit. The most recent conflation was House passage of Rep. Paul Ryan’s (R-WI) budget plan that included privatizing Medicare and turning Medicaid into a block-grant program—ideas that provoked outcry among seniors and others in town hall meetings around the country. Yesterday, Rep. Dave Camp, (R-MI) who is chairman of the powerful Ways and Means Committee, said that in the face of opposition from Democrats, he will not push forward with the Medicare privatization proposal. 

Continue reading →

In San Francisco, the “most costly user of publicly financed emergency health services…a ‘frequent flyer’ in emergency room parlance – is 49, Caucasian, schizophrenic, and addicted,” writes R. Jan Gurley, a board-certified internist who treats many homeless patients in that city and pens a blog titled “Doc Gurley: Posts from an Insane Healthcare System.”

Gurley continues; “He has been listed in at least two concurrent city systems as homeless (either continuously or episodically) for 16.6 years. He’s a frequent caller of ambulances (more than four times a month), a frequent user of detox and sobering center services, and a high utilizer of mental health services (including psych emergency). He is very, very ill.”

He is also costly to the public health care system. According to Gurley, last year the homeless man with this dubious honor “used an estimated $155,453 worth of emergency and urgent services alone (not counting other medical costs)” despite having a legal conservator and being enrolled in the city’s Department of Public Health intensive case management program.

Continue reading →

Here at HealthBeat, we often write about medical technology—the overuse of expensive imaging tests, unscrupulous relationships between doctors and medical device makers and the way these practices inevitably drive up the cost of health care. Our current health care system operates on the “build it and they will come” mentality—from spinal fusion devices to digital mammography to drug-eluting stents, we have seen demand ramp up in direct proportion to supply. Under health reform, this will clearly change as comparative-effectiveness and cost-effectiveness studies inform the government’s scrutiny of new technologies.

So how will this work in practice? An early test case may be the emerging technology of whole genome sequencing, the process of translating and cataloging an individual’s entire genetic code—all 3 billion base pairs that make up the “instructions” for life. Genome sequencing is a key component of “personalized medicine,” the Holy Grail for medical researchers who envision administering treatment that is targeted specifically to individual patients.

A handful of venture-capital-backed companies are developing nimble machines that can now sequence an individual’s genome in just a matter of weeks. This raw information—a kind of biotech version of tea leaves—is then sent to genetics researchers on a hard-drive, along with a list of identified single gene variations that might be involved in a patient’s cancer or other disease. These gene variations could also be harbingers of medical problems he or his family members might face decades from now. Although this is powerful technology offers great promise, right now whole genome sequencing is capable of offering practical help to only a very select group of patients.

Continue reading →

Joseph Rago, a senior editorial writer for the Wall Street Journal, won a Pulitzer Prize yesterday for a collection of pieces that mount a relentless attack on the federal health care law that he derogatorily refers to as “ObamaCare.”

Editorial writing by definition requires the author to take an opinion—and sometimes to offer prescriptive alternatives. The Pulitzer Prize board says Rago's columns are “well-crafted, against-the-grain editorials challenging the health care reform advocated by President Barack Obama.” And in the partisan battle that continues to surround health reform, clearly there is an important role for just this kind of bully pulpit. But if you read Rago’s body of work you will find editorials that are perhaps well-crafted stylistically (i.e. he’s not a bad writer), but his staunchly conservative opposition to the Affordable Care Act relies on oft-repeated mistruths. In fact, his criticisms of the health law pretty much go “with the grain” of those who have led the attack against not just the Affordable Care Act but against Obama’s leadership in general.

In fact, Rago’s series of columns promote opinions that are the standard fare on Fox News and spouted as fact by other right-wing pundits. He assails the individual mandate as unconstitutional, warns that “ObamaCare” actually is a government take-over of health care and charges that Accountable Care Organizations will lead to a dangerous consolidation of power that will increase costs by crushing competition and ending the “autonomy of independent practice.” He misstates figures concerning health spending and savings and repeats alarmist misinformation.

Continue reading →

At a meeting last week of health care journalists, Centers for Medicare and Medicaid Services director Donald Berwick unveiled a new government site called the Health Indicators Warehouse (HIW) that provides public access to what he calls “a treasure trove of data.”

According to Covering Health, the blog of the Association of Health Care Journalists, HIW includes “information never released before in an easily accessible form, including patient safety data, preventive health care indicators, Medicare payment claims and hospital performance at the state and hospital referral region level. Information is searchable by topic, location, health outcomes among other factors.”

Once on HIW, you can search for information on a whopping 1,119 health indicators—including adolescent health issues, hospital readmission rates, obesity statistics, patient safety data and many, many more—broken down by topic, geography and by initiative.

Continue reading →