Should We Change How Much Medicare Pays for Treatment vs. Prevention? --i.e. should smoking cessation cost more than cancer treatment?

The writer of the HealthBeat blog, Maggie Mahar, writes a very good and sometime provocative journal on healthcare in America. However, while I do see the merits of her recent column on pricing of healthcare services, questions have to be asked regarding how changing the pricing schedule would affect insurers’ behavior.

I can well imagine insurers’ reluctance to fund open-ended smoking cessation treatment even tho it may ultimately cost them less than treating the complications of smoking. The fact is, they are much more nervous about UNKNOWN total costs than they are about KNOWN costs for cancer treatment. For example, they can calculate to the dollar what a given course of treatment for a lung cancer is; they know how many radiation treatments will be requested, they know if chemo will also be part of the treatment protocol and how many chemo treatments, they know how many days of hospitalization will be involved. What makes them really nervous, again, is an unknown dollar amount for something like smoking cessation -- which does not end till the patient can actually give up cigs for good, and who knows how long that will take?

Look, Maggie Mahar, I agree with you completely on the relative worth of preventive or wellness interventions vs. treating the disease. But I think you have a real selling job to get the insurers behind any such pricing system.

It’s worth having a full and public discussion on these issues, tho, so I hope that this is not the last we hear of this idea.

When Medicare first created a fee schedule, critics suggested that it was a Marxist invention. Nevertheless, the schedule, which lists what Medicare is willing to pay for some 7,000 procedures, has become the master list for physician reimbursement in our health care system: most private insurers peg their payments to the Medicare schedule.
The notion of deciding the precise worth of some 7,000 diagnostic and therapeutic procedures is mind-boggling. How exactly does Medicare do it?
The process began in the late 1980s when officials at the Department of Health and Human Services decided that the way Medicare paid doctors should be overhauled. At the time, Medicare was reimbursing physicians based on what was considered “customary, prevailing and reasonable” in a particular market —in other words the “market value” of the service in that region.
Instead, reformers urged Congress to begin paying doctors in a way that reflected the real cost, to the doctor, of providing the service.

Please see her full article on this valuable issue at http://www.healthbeatblog.org/2008/08/today-we-pay-fo.html#more

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Big emphasis on HSAs and high-deductible plans

Many employers want to take a more active role in enticing workers to form the habits and get the recommended screenings that can protect their long-term health. To encourage employees to stick with preventive-care maintenance medications such as drugs to control high blood pressure, next year Guardian hopes to be able to waive the copay on such drugs, Mansberg said.

A growing number of employers are embracing incentive programs that reward workers who take health risk assessments, attend onsite health fairs or participate in biometric screenings, where they're measured for height, weight, blood pressure and other health-risk indicators, she said. "The vendors we work with make the information available to your primary-care physician so [he or she is] kept in the loop of what's going on."

A break on premiums or a small cash incentive can persuade busy workers to make their health a priority, Mansberg said. "A lot of times people will take care of their kids but they don't take care of themselves the way they should. It's another way to make it top of mind."

Full story from Market Watch -- www.marketwatch.com/News/Story/Story.aspx?guid=38e267addf124ae18d6733a44a95895a&siteid=nwtpf&sguid=-ELWpQNc4kyEAAp-GHdHfQ

Some employers are dropping formal group insurance coverage completely or just sign up with administrative services like AdminiStaff. The advantage of these outside administrators is that it saves the company hours of processing time for check deductions, while allowing employees to pick and choose insurance plans that fit their needs.
Not selling you anything -- just acknowledging that there are other options out there that are catching on.

Taking Path of Travel Provision out of Disabled Americans Law Would Gut It

The current proposed changes to the Americans with Disabilities Act have several good points but some are strangely contradictory. The most glaring example of a proposed change that would effectively gut the whole law is the one about ‘path of travel’.

According to an advocacy group for the disabled, the Disability Rights Education and Defense Fund (DREDF), the Department of Justice proposal is that “if alterations are made to a public accommodation or public entity’s are of primary function, it does NOT have to bring the path of travel to that area into compliance” with the 2004 Americans with Disability law. In other words, if the local courthouse or library remodels the entrance, it will no longer matter if a disabled patron can get from the parking lot to the lobby? Is that what they really mean to say?

Because if there is no ramp for a wheelchair, or the door is no longer wide enough to admit a wheelchair, or if there is no longer an elevator, or no low buttons on the elevator, etc. etc. then there may as well be a Berlin Wall in front of that library or courthouse or other public facility.

We have come so far in terms of integrating disabled persons of many kinds into public and private buildings and businesses, places of work and play and recreation. I might add that while the numbers of long-term disabled is fairly steady, the ranks of short-term disabled could include any of us reading this story now.

Millions of Americans are “disabled” for a short term whether or not it is formally or informally recognized. Everyone who has broken a limb -- or had a stroke -- or a heart attack -- or any surgery -- has had to learn how to cope like a “disabled” person. They’ve had to try to carry on with normal activities like going to a grocery store, movie theatre, bank, or post office. You haven’t lived till you tried opening a jar of pickles with your left hand because the right one is in a cast.
The husband of friend had a heart transplant several years ago, and his wife said that they would get a few funny looks when they parked in the handicapped parking. Her husband’s disability was not visible, so onlookers assumed they were taking advantage of the parking space without cause.

I have had several experiences of taking my mom (post-stroke) or an aunt (multiple health problems) to the grocery store or doctor appointment and been glad that there were wide doorways, ramps, etc so that we could get from point A to point B without a hitch. Fortunately neither one lived in a fourth floor apartment without an elevator or I really would have been in a jam.

While I cannot speak about the specifics on whether a pool-lift needs to have foot-rests or not, I think I can say with some certainty that an American with Disabilities law REALLY needs a ‘path of travel’ provision.

[Please see a story about proposed changes to the ADA here at http://minnieapolis.newsvine.com/_news/2008/08/11/1740611-appalling-doj-proposals-would-weaken-disability-act-provisions?last=1218505510#dynamicCommentBox_2427716 and the webpage from the Disability Rights Education and Defense Fund (DREDF) with their discussion of the proposed rule changes here at http://www.dredf.org/DOJ_NPRM/ ]

Is there a “Right” to Medicare? Should 'Grandma' Pay for Her Own Cataract Surgery?

There has been quite a rumpus in articles about whether Medicare should refuse to pay for certain procedures due to the financial straits it once again is in.
In other words, do well-off seniors have the right to have Medicare pay for procedures that they could afford to pay out of pocket? And would this really help Medicare’s financial predicament anyway?

From someone called

the Happy Hospitalist believes that it is time to “say No” to seniors. “No to dialysis. No to life support. No to elective procedures [which would include artifical hips and knees] . No to brand name drugs. No to the latest expensive technology. We will have to place greater weight on quality of life over quantity of life. We will have to demand hospice care in futile situations. We will have to demand palliative comfort over slice and dice. We will have to reject marginally effective proceduralization and imaging of our elderly. We have to. We don’t have a choice. There is no other way.”

When I look at this list I agree on some items. “Futile care” is clearly unnecessary care. But often, we don’t know whether or not it will be futile. Every day elderly people do emerge from ICUs and go home to play with their grandchildren. As for “brand new drugs,” and “the latest expensive technology” regular readers know that I believe that everything depends on whether the new technologies have been tested and proven effective. We cannot afford to squander Medicare dollars on drugs, devices and procedures without knowing whether the patient will benefit. And I certainly prefer palliative care over “let’s try another surgery. Can’t do any harm.” (Except to the patient who suffers through it).

I agree with some measures but not others. Maybe all these joint replacements are unnecessary because we have been going about it all wrong. But cataract surgery keeps seniors active and involved and self-sufficient -- those are good things, dammit.
http://www.healthbeatblog.org/2008/08/do-seniors-have.html#more

Millions With Chronic Disease Going W/O Insurance or Treatment

A new study to be published this Tuesday in the medical journal Annals of Internal Medicine estimates that one of every three working-age uninsured adults in the U.S. has been diagnosed with a chronic illness -- diseases such as diabetes or high blood pressure.

Even though their conditions could be successfully managed, they are going without even doctor visits to monitor their progress. Instead, they rely on very expensive emergency room visits.

The actual figure now of uninsured Americans is 47 million; the study estimated that about 11 million (of the 36 million uninsured in 2004) had been diagnosed with a chronic condition. Nearly a fourth of the uninsured said they had not visited a doctor in the past year. The total number with such a condition may be higher for two reason: the growth in the number of total uninsured since 2004, and the fact that people may have developed such a condition in past year and not know it.

We can do better than this, people. Forty seven million uninsured is a disaster waiting to happen.

Info from New York Times report at http://www.nytimes.com/2008/08/05/business/05health.html?_r=1&adxnnl=1&oref=slogin&ref=health&adxnnlx=1218316447-mchkYD402MaReOGqwa1txg

McCain Health Care Plan Glosses Over Fact that Key Provider Info Hard to Come By; How Then is Consumer to Choose?

One of the big campaign issues is what each candidate proposes to improve the state of health care in this country. The United States spends far more per capita and seems to get less for the dollar compared to nations with some form of national health plan.

The McCain campaign claims that consumers will benefit by being empowered to choose their own providers and buy their own health insurance. He plans to eliminate the tax incentives to employers for providing coverage to their employees. It seems reasonable that if the tax breaks are in fact eliminated, then employers will no longer offer any form of insurance coverage as a benefit to their employees.

Left to their own devices, Americans may think that they can just muddle ahead but will soon find that the data one would need to make these provider choices is difficult if not impossible to come by. And while some providers may post some information on their websites, it may not be in the same format as another provider’s. Consumers are left trying to compare apples and oranges.

The federal Agency for Health Care Research and Quality (AHRQ) found that there are 12 different rating schemes for doctors, 26 for medical groups, and 81 for hospitals, and 86 for health plans. Even the most intrepid, determined consumer is hard pressed to research all of that data and find a doctor who meets their needs. How many of us have the time to research even a fraction of those databases or of the health care providers in their county? Good luck to you even if you do have the time.

The Alternet website has a good article in their recent issue. I cannot quote any excerpts, but here is a link to the story -- http://www.alternet.org/mediaculture/94154/?page=entire. You may also check amednews.com