Dear HealthBeat Readers,

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As I have mentioned in the past, I am now posting on null.com as well as here on HealthBeat.  (I write separate pieces for the two sites; sometimes we cross-link the posts.)

Healthinsurance.org (HIO) is a consumer-focused guide to health insurance and a vocal advocate of health care reform. An independent web site, it was founded in 1994 to arm consumers with the information they need to understand insurance coverage and health reform proposals, compare policies and find affordable medical insurance. HIO is not an insurance company or broker, although it links to sites where shoppers can get pricing and information on plans.

HIO’s articles and blog posts from health care writers are more often than not critical of the insurance industry for long-standing practices that include denial of coverage due to pre-existing conditions, cancellation of policies when customers fall sick, and the industry’s failure to include maternity benefits in most individual plans.

Today, both Linda Bergthold (who worked on the Clinton Health Reform plan and was the head of the Obama health care blog team in 2008) and U. of Chicago ProfessorHarold Pollack (who has published widely about poverty policy and public health) contribute to null.com. I urge you to take a look at their posts. (Just go to the top of the site’s homepage and click on Blog.)

Below, you will find the first section of a post that I published on null.com about a week ago, with a link to the rest of the piece.

This week, HIO published another post where I attempt to counter the fear-mongering about reform. Gloomsters predict that as more Americans are insured, doctors’ waiting rooms, hospitals and ERS will be packed. Some of reform’s opponents warn that you won’t be able you get an appointment with your own doctor. Others suggest that as demand for medical care rises, so will prices.

The number-crunchers at Price Waterhouse Cooper’s Health Research Institute have just published a report telling us that this is Not True.  Check out the post.

Finally, long-time readers no doubt noticed that when I re-launched HealthBeat last summer, the website sported a new, greatly improved design.  It’s sharper, more attractive, and the “search” engine works!

When I began writing for healthInsurance.org last spring, HIO founder Charles Smith-Dewey volunteered to give HealthBeat a new look.  He also offered to host HealthBeat on his server.  Many thanks to Chuck for his generosity—I couldn’t have brought the blog back to life without HIO’s help.

Thanks also to HealthBeat readers for their loyalty and their comments. (Readership is back to where it was, and is growing.)

Finally, if you’re not getting e-mails telling you when I have published new posts, just go to “Subscribe to Maggie’s Updates” in the upper-right corner of this page.

 

Could President Romney repeal Obamacare? No.

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 Mitt Romney’s web site makes a bold promise: “On his first day in office, Mitt Romney will issue an executive order that paves the way for the federal government to issue Obamacare waivers to all 50 states. He will then work with Congress to repeal the full legislation as quickly as possible.”

Many of Romney’s supporters assume that this is what will happen if he wins. But in truth, even if Republicans take both the White House and the Senate, Romney wouldn’t have the power to “repeal the full legislation.” Nor could a new president grant waivers that would let states ignore the Affordable Care Act (ACA). We live in a nation ruled by law, not magic wands.

That said, those who support reform should keep a close eye on the Massachusetts Senate race, where Democrat Elizabeth Warren is challenging Republican Senator Scott Brown. The outcome could determine whether Democrats continue to hold 53 seats out of 100. (Political analysts rate Brown and Nevada’s Dean Heller as the two most vulnerable Senate Republican incumbents. If Republicans win the Senate, they won’t be able dismantle reform, but they could do serious damage to the ACA, by eliminating the subsidies that will help middle-class and low-income Americans purchase insurance. But even if they take over the Senate they will not be able to change the new rules for insurance companies.

                                    Romney’s Promises – and Why You Can’t Believe them

Begin with the “Obamacare waivers” for the states.

“There are no ‘Obamacare waivers’ that could be issued by executive order,” Washington & Lee health law scholar Timothy Jost explained in a recent phone interview. That’s right: these waivers simply don’t exist. Here, we’re tripping over one of those “Big Lies” that have become a feature of the Romney campaign. (Nazi propaganda chief Joseph Goebbels was the master of the tactic: if you tell a colossal lie, and repeat it often enough, people will believe it, not matter how outrageous. After all, who would make up such a whopper?)

On the HealthAffairs Blog, Jost elaborates :

You will find the rest of this post on HealthInsurance.org If you like, you can return here to comment.

Truth Squad: Is “Obamacare” Pushing Health Care Spending Higher? What Will Happen in 2014?

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In last Tuesday’s debate Mitt Romney suggested that, under Obamacare, health insurance premiums have spiraled by $2,500 per family. Not true.  (Hat tip to Healthcarefinancenews.com.)

 First let’s get the number right: According to an annual survey of employer plans  by the Kaiser Family Foundation and Health Research & Educational Trust, since the Affordable Care Act (ACA) passed in 2010, the average annual premium for family coverage has risen by $1,975 not $2500.  $1975 is a hefty sum, but 20% less than Romney claimed.

More importantly, $1,975 represents the combined increase in contributions made by employers and employees— with employers picking  up the lion’s share of the hike. “In reality, premiums paid by employees haven’t changed that much.” Factcheck observes. In fact, when you look at the rise in how much employees contributed, “the federal health care law was responsible for a 1 percent to 3 percent increase because of more generous coverage requirements.” In other words, employees were paying a little more, but getting value for their dollars.

After telling a whopper about how much employee’s health care premiums have risen in the past, Romney went on to assert that if Obamacare is  “implemented fully, it’ll be another $2,500 on top” of that. His evidence?  None.

                                              The Media Spreads the Myths

Yet the media continues to swallow the notion that under “Obamacare” health care spending will levitate. A few days ago, the Washington Post’s Robert J. Samuelson wrote: “Almost every expert agrees that controlling health costs is the crux of curing chronic budget deficits. Health-care spending already exceeds a quarter of federal outlays. With Obamacare’s coverage of the uninsured starting in 2014 and retiring baby boomers flooding into Medicare, the share is headed toward a third.”

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Breakfast with Atul Gawande

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Sunday, Boston Surgeon Dr. Atul Gawande spoke at the New Yorker Festival about the importance of a hospital being able to “Rescue Success from Profound Failure.”   (Long-time Health Beat readers will recognize Gawande as the author of Complications: A Surgeon’s Notes On An Imperfect Science, The Checklist Manifesto  and a number of brilliant New Yorker articles that I have written about in the past, including: “Letting Go: What Should Medicine Do When it Can’t Save Your Life?”,  “It Will Take Ambition It Will Take Humility,” and  “The Fight for the Soul of American Medicine”  (Hat-tip to the New Yorker for publishing so many stellar articles illuminating an extraordinarily complicated subject: healthcare and healthcare reform.)

Before Gawande’s talk began, IBM, the event’s sponsor, hosted a small breakfast where Gawande spoke informally to a group of doctors, health plan executives, hospital administrators and people from IBM who are in the vanguard of healthcare reform. The New Yorker was kind enough to invite me to attend the breakfast and blog about the conversation.

                              Less Expensive Medical Care Can Mean Better Care   

At Sunday’s breakfast Gawande began by observing that “in just the past four or five years we have seen a huge shift in the national conservation about health care.” Since 2007 or 2008 many have come to realize that when it comes to medical care in the U.S., “there is no direct relationship between the amount of money spent and positive results.”  In other words, although we spend twice as much as many other developed countries on health care, medical care in the U.S. is not twice as good. In some ways it is worse.

Yet this epiphany is not as discouraging at it sounds. As Gawande pointed out, “Recognizing that expensive care does not necessarily equal top-quality care has enabled a decoupling of the two issues in the public mind, and opened up the possibility for real beneficial change in the system. The Affordable Care Act’s goal” of securing high quality care for everyone is, in fact, affordable. “We don’t have to ration care.”
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The Electronic Medical Record and the Disappearance of Patients’ Stories

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Below, a guest post by Christopher Johnson, a physician who has practiced pediatric critical care for more than three decades. For many years, Johnson served as the Director of the Pediatric Critical Care Service at the Mayo Clinic and Professor of Pediatrics at Mayo Medical School. Today, he devotes his time to practicing pediatric critical care as President of Pediatric Intensive Care Associates, P.C., i n St. Cloud, Minnesota, and as Medical Director of the PICU for CentraCare Health Systems.

In addition, Johnson writes about medicine for general readers, both on his blog  and in books such as HowYour Child Heals: An Inside Look at Common Childhood Ailments  and How to Talk To Your Child’s Doctor: A Handbook for Parents

Not a few doctors complain that, too often, electronic medical records seem designed to improve billing, rather than to improve care. Johnson suggests that today’s EMRs are trying to serve too many masters—not just doctors, but payers and lawyers who want to see information laid out in easy-to-read “templates.” 

With a single keystroke, one can “drag and drop” information from previous notes into these templates, Johnson observes. But when physicians use them to record their progress notes, something important is lost: the patient’s story. Traditionally, progress notes set out to “tell, from day to day, what physicians did to a patient and why,” Johnson explains. They are a narrative that fleshes out the patient’s history in a way that helps other doctors treating the same patient.

Johnson uses and appreciates the many ways that EMRS can help him. But when writing out his progress notes, he ignores those smart templates, and tells the story the old-fashioned way, typing out his progress notes, just the way he did when he used pen and paper. Not only does this help other doctors, but Johnson says, it gives him a chance to “think things through.”

Narrative connects the dots.

—MM

The Electronic Medical Record and the Disappearance of Patients’ Stories   

By Chris Johnson, M.D.

The electronic medical record (EMR) is here to stay. Its adoption was initially slow, but over the past decade those hospitals that do not already have it are making plans for implementing it. On the whole this represents progress: the EMR has the ability to greatly improve patient care. Physicians, as well as all other caregivers, no longer have to puzzle over barely legible handwritten notes or flip through pages and pages of a patient’s paper chart to find important information.

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“The Third Rail of Payment Reform”–Tackling Wide Variations in How Much Providers Charge

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Why do some hospitals and doctors charge far more than others for exactly the same routine procedure?   “Because they can; it’s not any more sophisticated than that,” says Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance and … Continue reading →

Why Market Competition Will Not Lower the Cost of Health Insurance

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 “Competition drives improvements in efficiency and effectiveness, offering consumers higher quality goods and services at lower cost. It can have the same effect in the health care system, if given the chance to work.”– Mitt Romney

Creating “robust competition” is at the core of Mitt Romney’s approach to Health Care Reform. He would be right–if health care were commodity like any other.  In many industries when more sellers compete for customers, prices come down. Think of thin-screen TVs.  But the healthcare market is not like other markets, as a great many health care economists have explained.

When it comes to medical care, the consumer does not have the leverage that he enjoys in other markets because there is too much uncertainty about a) what he needs, and b) the value of what is, in the end, a very complicated product.

First, consider his needs: Should he purchase an expensive, comprehensive policy with no caps on annual or lifetime payouts? If he has a big family, he knows he needs a big car. But he has no way of knowing whether he, his spouse or one of his children will develop cancer, MS., Alzheimer’s or be in an accident that leaves one of them paralyzed for life. So there is no way that a savvy consumer can bring down insurance prices by shopping for the “least expensive policy that fits his needs.”

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Hospitals Under Scrutiny For Billing Practices That Cost Medicare $11 Billion

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Below, a guest-post from Naomi Freundlich. This post originally appeared earlier this week, on Reforming Health , Naomi’s new  blog. (Many Health Beat readers will remember Naomi as Health Beat’s associate editor back when we were both working for The Century Foundation.)  

************************************************************************************************
If you or a loved one has been to the emergency room lately you might want to request an itemized bill. The highest charge will likely be for what is known in billing parlance as “evaluation and management” services. These services include taking a patient history, performing an initial exam and directing treatment. How much the hospital charges will depend on an all-important choice of billing code—there are a range of codes that coincide with factors like the severity of the problem, underlying health issues of the patient and in some cases, time spent managing this care.

Why take a close look at these charges? According to a new investigative report from teh center for Public Integrity  providers have been increasing their use of billing codes that correspond with care for the most seriously ill or injured patients, adding $11 billion or more to the fees they receive from Medicare over the last decade.

According to the CPI report; “Use of the top two most expensive codes for emergency room care nationwide nearly doubled, from 25 percent to 45 percent of all claims, during the time period examined. In many cases, these claims were not for treating patients with life-threatening injuries. Instead, the claims the Center analyzed included only patients who were sent home from the emergency room without being admitted to the hospital. Often, they were treated for seemingly minor injuries and complaints.”
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Paul Ryan’s Plan for Medicare: A Disaster for Seniors (Why Doctors Might Stop Taking Medicare)

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“Robin Hood in reverse, on steroids”–that’s how Robert Greenstein, President of the Center on Budget Policy and Priorities (CBPP),  has described vice-presidential candidate Paul Ryan’s blueprint for the 2013 budget: It could likely produce the largest redistribution of income from the bottom to the top in modern U.S. history.”

I quoted Greenstein in April, in a post that originally appeared on HealthInsurance.org. There, I explained that Ryan’s budget would shift Medicare costs to seniors  and slash Medicaid, while simultaneously offering tax breaks for Americans perched on the top of a our income ladder.

Under the newest version of the Ryan plan, Washington would give seniors a voucher equal to the cost of the second-cheapest private-sector Medicare plan in their region. In theory, this gives seniors “choice” — the opportunity to pick a Medicare policy that best suits their needs, and their pocketbook.

If they don’t want to buy a plan from a for-profit insurer, they could, if they wish, use the voucher to buy traditional government-sponsored Medicare–though if it costs more than that second-cheapest private plan in their area, they will have to make up the difference.

Romney and Ryan are convinced that the private sector is always more efficient than government. Thus, for-profit insurers will be bound to offer better care at a lower price. Their faith is remarkable, given that past attempts to privatize Medicare (Medicare + Choice and Medicare Advantage) have largely failed on both counts.

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The Art of Diagnosis: “True Medical Detective Stories”

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Below an excerpt from Dr. Clifton Meador’s newest book: True Medical Detective Stories, a collection of true tales about patients who presented with symptoms that mystified their doctors (June, 2012).  In each case, the doctor eventually cracks the mystery, but only by “listening–very carefully” to the patient. 

The book begins with a dedication to the late Berton Roueché, who popularized the medical-detective genre as a staff writer for the New Yorker.

Following the excerpt, I have added a Note on the author.

A Young Doctor and a Coal Miner’s Wife

                                        By Dr. Clifton Meador

A young doctor, Dr. Bill Hueston, and his wife had just moved to the mountains of eastern Kentucky, near the border of West Virginia. The small town was nestled among the coal mines of the region. Nearly all of his patients would be coal miners or family members of a miner. Bill would practice family medicine. His wife, a veterinarian, hoped to build a small-animal practice.

Liz McWherther, the forty-seven-year-old wife of a miner, came to see the young doctor. Over several weeks, she had developed a curious set of complaints. Each morning she woke with a dry mouth and slurred speech. She also noted blurred vision and difficulty urinating. Within a couple of hours of waking, she was completely free of any symptoms. These symptoms had been occurring each morning and going away by afternoon.

Liz had had a series of tests done by the previous physician, but none of these tests were abnormal. The physical examination by Dr. Hueston was entirely normal. She denied drinking alcoholic beverages or using illicit drugs. Hueston had briefly considered some unusual response to marijuana or other drugs that were prevalent in the area. Liz had not been down in the mines, nor did her husband bring back anything unusual into the house.

The complex of symptoms suggested multiple sclerosis or some diffuse neurological disease. However, the rapid disappearance of the symptoms was puzzling. The most perplexing feature was the improvement as the day went on. Nearly all neurological diseases get worse as the day progresses. In most cases after a night’s rest, the neurological circuits are improved, and patients are at their best on arising. Not so with Liz. She was at her worst on arising and rapidly improved within a few hours.

Dr. Hueston went through a long list of possible neurological conditions. None seemed to fit the findings or course of the symptoms. Hueston came to the conclusion that he needed a neurological consultation. The nearest neurologist was over fifty miles away, so he began filling out the request for consultation and other forms required by the miners’ insurance.

Hueston was chatting as he wrote. “My wife and I are new to the area. You know she is a veterinarian. She’s having a hard time dealing with the amount of skin disease in her patients. All of the cats and dogs are loaded with ticks and fleas. She didn’t have that problem in her city practice

Liz’s attention became alert. “Yeah, I had that with my cat. But I fixed it.”

“How’d you get it fixed?”

“I just dust her every week.”

Hueston stopped writing and paused. “You dust her. What do you mean ‘dust her’?”

“I just take my rose dust I use in my garden. Dust it on my cat. Then just rub it in.”

Hueston asked, “Rose dust? What’s that?”

 “I don’t know what all’s in it. It kills the insects on the roses and it sure kills ticks and fleas on my cat. My cat is free of ’em.”

Hueston, now in full alert, asked, “Where does the cat sleep?”

Liz smiled and answered, “Why, she sleeps right on my pillow with me.”

Hueston said, “I want you to go home and wash your cat. Don’t use the rose dust anymore, and don’t let the cat in your room at night. Let’s see what happens and maybe you won’t have to go all the way to Lexington.”

Liz came back a week later. Smiling widely, she told Dr. Hueston she had not had any more dry mouth, blurred vision, or slurred speech. Her urination was completely normal. The “disease” had gone away. She even brought a bag of the rose dust with her.

Dr. Hueston smiled back. He read the chemical contents on the rose dust bag and found what he suspected in the contents—organophosphates.

He went on to explain to Liz McWherther how organophosphates are nerve poisons. They cause some segments of the nervous system to fire continuously. The pupils constrict to pinpoint size. Salivation is inhibited. The urinary bladder does not function normally. If the exposure to organophosphates continues or the dose is large, death can occur.

Everyone wondered why the cat did not get sick. We will never know. Liz’s problems were symptoms that she noted and described.

Cats don’t talk.

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A note on the Author: Clifton Meador has been practicing and teaching medicine for more than 50 years and some of the patients he describes in these stories are his own.

Not only is Meador an engaging story-teller (he has been called the “Will Rogers of medicine”) he  has had a lasting impact both as a doctor, and as someone who has thought deeply about how medicine is practiced in the U.S. His well-known satirical writings on the excesses in our the medical system include “The Art and Science of Nondisease, (the New England Journal of Medicine, 1965) and “The Last Well Person,” an essay he published as an “Occasional Note” in NEJM Journal in 1994.

 “The Last Well Person” begins with this anecdote: “A supervising doctor asks a medical resident “What is a well person?” The resident  replies with some confidence: “A well person is a patient who has not been completely worked up.”

Meador then proceeds to tell a tale takes place in the not-too-distant future. The story’s only character is a 53-year-old professor of freshman algebra at a small college in the Midwest. Despite extensive medical evaluation, no doctor had been able to find anything wrong with the teacher. But he is the only remaining person for whom this is true. Doctors from all over the country flock to the Midwest to check him out.

At the time, Meador warned: “if the behavior of doctors and the public continues unabated, eventually every well person will be labeled sick.” (Dr. Norton Hadler would later adopt the title for his book The Last Well Person: How to Stay Well Despite the Health-Care System, 2004)

 HealthBeat readers who have seen the film version of Money-Driven Medicine http://moneydrivenmedicine.org/ (produced by Alex Gibney, directed by Andy Fredericks) may remember Meador as the Nashville doctor who takes them on a tour of his town. Nashville is best known as the nation’s Country Music Capital, and Meador takes readers past “Music Row,” but as he r reveals, Nashville also is the headquarters for a “massive complex of healthcare corporations.”     

Their pristine headquarters are set high on a hill. In most cases, there are no corporate logos, no signs to identify who the companies are. (Perhaps they are trying to avoid surprise visits by Michael Moore.) But as he drives past, Meador identifies them:

“We have three mother corporations here:  HCA, which is the Hospital Corporation of America, spun off all of these. Hospital Affiliates, which is a spin-off of HCA, and Health Trust, which is a spin-off of Hospital Affiliates and HCA, spun off all of these. So this is a massive, industrial health complex that’s headquartered here in Nashville.” In the background, we hear the song that Alex Gibney, the film’s producer, chose for this scene: “If you’ve got the money, honey, I’ve got the time.”

Over the years, Meador has watched Nashville’s medical industrial complex develop into one of the country’s biggest money-spinners, while, at the same time, health statistics in Tennessee have slid to the bottom of the national rankings