Dr. Aaron Carroll on Stand Up with Pete Dominick (Audio)

Pete Dominick, host of Stand Up with Pete Dominick on Sirius XM radio Indy Channel, interviews Dr. Aaron Carroll, from the Indiana University School of Medicine. Dr. Carroll is a frequent guest on the program where he discusses various issues within health policy.

In this interview Dr. Carroll discusses the care at the Veterans Administration, why reforming Medicare and Medicaid is hard, why the transition to an improved way of handling medical information is coming along slowly and takes a few questions from listeners...

Click here to listen to it. It runs about 33 minutes in length...




Source:

http://theincidentaleconomist.com/wordpress/wp-content/uploads/2013/03/03-20-13_DrAaronCarroll.mp3

Proposed Medicare Cuts: Summary from Politico...

Politico has a pretty comprehensive write-up on the proposed cuts to Medicare as part of the "fiscal cliff" talks. The bottom line is that the entitlement program being cut does save the government money. Those costs are passed on to the people approaching the medicare eligibility age of 65. This group will almost certainly see an increase in their health insurance premiums. The increases would likely be phased in "gently" over a ten year window.

Read the article here...

Politico: The cold, hard realities behind Medicare cuts...

Source:

http://www.politico.com/story/2012/12/medicare-cuts-84493.html

Paul Krugman: Paul Ryan Not A Serious Man...

It's not surprising that economist Paul Krugman finds little to like about Republican Vice Presidential nominee Paul Ryan's tax ideas. Its not really surprising how Krugman dissects the "Ryan" plan and the "seriousness" that is supposed to come with it.

A preview of today's column from the New York Times:

"The answer, basically, is a triumph of style over substance. Over the longer term, the Ryan plan would end Medicare as we know it — and in Washington, “fiscal responsibility” is often equated with willingness to slash Medicare and Social Security, even if the purported savings would be used to cut taxes on the rich rather than to reduce deficits. Also, self-proclaimed centrists are always looking for conservatives they can praise to showcase their centrism, and Mr. Ryan has skillfully played into that weakness, talking a good game even if his numbers don’t add up."

Find and read the entire column here...

Source: 

http://www.nytimes.com/2012/08/20/opinion/krugman-an-unserious-man.html?smid=tw-NytimesKrugman&seid=auto

Medicare Penalties To Kick In Soon for Hospitals With Excess Readmissions - A Good Thing?

 In most businesses, there's some implied warranty that goes into effect immediately after the purchase is transacted. You buy a car and it develops engine trouble after two weeks, you're very likely to see the dealer step up, provide the repairs at virtually no financial cost to you. They are trying to build a relationship as much as anything and prompt response to a customer's problem is an effective way to achieve that. If you've bought an extended warranty, you're protected for an even longer time.

Let's look at a completely different type of business, food service. There are no additional warranties available for purchase at any restaurant I know of, so the addressing of an unhappy customer happens on the spot. Items are replaced and in some cases, that's all there is to it. In other more troublesome cases, the business will reduce the size of the bill and/or offer some incentive for the customer to return once more.

Looking at healthcare, there has never been this type customer satisfaction device utilized on a widespread basis. Nor could there be a program that looks very much like anything we'd recognize as a warranty/customer satisfaction offering. Health care, by its nature, its unique and different. Things aren't always discovered or known to be wrong until a much later time measured in weeks not days, plus the dire nature of a medical problem is held in a much higher priority than that of an over-cooked steak.

Starting in October of this year, hospitals experiencing a higher than expected readmission rate, (based on 30 day readmits) will be penalized by Medicare. According to Kaiser Health News, as many as 2,000 hospitals will forfeit about 280 million in Medicare reimbursements due to this issue.

As part of the Affordable Care Act, the government is trying to reduce the number of unnecessary re-admissions in hospitals. Roughly one in five Medicare patients are readmitted within 30 days. Traditionally, hospitals have have little incentive to ensure patient recovery and have in fact benefited financially when patients are re-admitted. The ACA attempts to force hospitals to focus more resources on a higher quality outcome after discharge. The penalty this year is 1% of these hospital base Medicare reimbursement. The penalty increases next year to 2%.

On the surface, a program that incentivizes quality should be considered a good one. No one wants to see a loved on have to return to the hospital because the discharge treatment plan wasn't a success. However, there are other factors that may be relevant. According to the New England Journal of Medicine article, "Thirty Day Readmissions-Truth and Consequences" written by Karen E. Joynt and Ashish K. Jha, often issues that arise after several weeks are beyond the control of a hospital. Some re-admissions (actually most) are not preventable. Drivers of re-admits like mental health issues, poor social support and poverty all effect the metric. Hospitals with high re-admissions are often serving a poorer socio-economic group which doesn't necessarily translate to substandard post discharge care. Also, the cost of reducing re-admissions may effect available fiscal resources for patient quality and safety within the hospital.

They add...

In fact, there are several factors influencing readmission rates that we would not want hospitals to change. For example, hospitals with a low mortality rate among patients with heart failure have higher readmission rates, presumably because they keep their sickest patients alive, and those patients are subsequently more likely to be readmitted.4 Similarly, given the close relationship between overall community-level hospitalization rates and readmission rates, communities that invest resources in outpatient care and thus are able to keep their healthiest patients from being hospitalized may see their readmission rates rise. Finally, whereas some studies have shown that sustained efforts can reduce readmission rates somewhat, others have shown that interventions aimed at improving care coordination and access to follow-up care actually increased the rate of readmissions, presumably because of improved access to needed care, with commensurate improvement in patient satisfaction.5 These interventions should hardly be seen as failures.

Joynt and Jha also suggest a shorter time frame of 3-7 days as a more appropriate time frame in which CMS should penalize facilities.

On the surface, its an admirable goal to reduce re-admissions. Its a sensible thing. Only time will tell if the effort turns out penny wise and pound foolish.

Sources:

Medicare To Penalize 2,211 Hospitals For Excess Readmissions - Kaiser Health News:

http://www.nejm.org/doi/full/10.1056/NEJMp1201598

Another Affordable Care Act Lie Exposed...

It seems that one can't go for more than a week or so before running into yet another falsehood being spread around the internet about President Obama's Health care reform, the Affordable Care Act. Last week I heard the meme that buried within the pages of the Bill's text was the notion that anyone who sold a home would have to pay an additional 3.8% "health care tax" on the transaction. I'd heard it before, but sometimes these things have a life of their own. The claim is FALSE. Its de-bunked here, here and here...So, the next time you hear or see of someone spreading that misinformation around, please correct them.

Here's one I hadn't heard before.

This one focuses on an alleged increase in Medicare Insurance Premiums due to Obamacare. There is a viral email of course that claims the prices are about to skyrocket, mentions buzzwords like "mainstream media" and explains that this information is being kept quiet until the 2008 presidential elections are over. Sigh...

Here's a great write-up on it from John E. McDonough of the "Health Stew Blog" that I've referenced before:

Lots of folks ask me why I think the Affordable Care Act/ObamaCare is so unpopular. I first assert that it's not as unpopular as popularly characterized (see Kaiser Family Foundation monthly tracking polls) and then I refer to the deliberate and false claims about the law being widely circulated around the nation, particularly aimed at senior citizens. I wrote about one particular falsehood last month. Now, my newfound pals at the GE Retirees Association yesterday sent me another they have been receiving in their email inboxes:

Subject: Medicare Premiums ---FYI
MEDICARE
Look clearly at the 2014 rate compared to the 2013 rate.
For those of you who are on Medicare, read the following. It's short, but important and you probably haven't heard about it in the Mainstream News:
"The per person Medicare Insurance Premium will increase from the present Monthly Fee of $96.40, rising to:
$104.20 in 2012
$120.20 in 2013
And
$247.00 in 2014."
These are Provisions incorporated in the Obamacare Legislation, purposely delayed so as not to confuse the 2012 Re-Election Campaigns. Send this to all Seniors that you know, so they will know who's throwing them under the bus.
Peggy Riehle
Internal Representative
Network Contracting
205-220-6778

Could I verify or contradict the message, my GE Retiree friends wanted to know. Didn't sound right to me, so I did some investigating. My contacts in the Obama Administration and the U.S. Senate said it's a viral email lie that has been going around for more than one year now. 

Needless to say, the email is a pure hoax, which the people at Blue Cross Blue Shield Alabama have been trying correct for a while now. Click here to continue reading McDonough's piece...


Sources:

http://www.forbes.com/sites/beltway/2012/04/02/there-is-no-obamacare-tax-on-most-home-sales-really/

http://taxfoundation.org/blog/show/26741.html

http://www.snopes.com/politics/taxes/realestate.asp

http://www.boston.com/lifestyle/health/health_stew/2012/04/anatomy_of_another_aca_lie.html

Fed making progress in Medicare Fraud...big bucks recovered...

Feds Recover Record Number Of Health Care Fraud Judgments: via HuffPost
Good news in this article...

Sick and tired of Medicare/Medicaid fraud? Good news to report...

A great read from John McDonough's Boston Globe blog on health policy. McDonough writes on the dramatic improvement on fraud reduction under the Obama administration. Remember folks, these are your and my tax dollars being saved...Keep in mind that, as the author suggests, every republican candidate has pledged to repeal "Obamacare" as soon as possible once they enter office. That means programs like this one are potentially on the way out as well...Think about that...

ObamaCare Is Winning the Fight on Fraud and Abuse

Members of Congress of both parties often complain about fraud and abuse in Medicare and Medicaid (M&M), usually charging that the President is not doing enough to keep bad guys from stealing money from these vital programs.

Guess what? Thanks to provisions in the Affordable Care Act (ACA/ObamaCare) and to an unprecedented effort by the Obama Administration, more progress has been made in the past three years to combat health care fraud and abuse than ever before. There was a 68.9 percent increase in criminal health care fraud prosecutions from 2010 to 2011, and 2010 was already the highest ever. See the chart below, released last month by the Transactional Records Access Clearinghouse at Syracuse University. (Note: NPR did a fine piece on this topic last Friday.)

Figure 1: Criminal Health Care Fraud Prosecutions over the last 20 years


Everybody knows there is a lot of fraud in M&M, though no one really knows how much. In the 1990s, the FBI made a back-of-the-envelope calculation of 10%, a never-validated estimate which has assumed undeserved biblical truth status. There's a lot, no doubt. Back in 1997, the New York Times reported that crime families were dropping drugs, prostitution, and gambling to get into health insurance fraud because the money was so much easier to steal.
Someone once told me the most successful day in the history of the Internal Revenue Service was the day they sent Martha Stewart to jail -- because so many folks had the thought, "if they will send Martha to jail, why would they treat me any better?"  Same with these stats -- it is not just the numbers who get caught and go to jail -- and one bad guy was sent up the river for 50 years -- it's everyone ought there who now realizes they have a bigger chance of getting caught.

Continue reading here...

Source:

http://www.boston.com/lifestyle/health/health_stew/2012/01/obamacare_is_winning_the_fight.html?camp=obinsite

We spend a lot of money on hospital re-admissions...

The Dartmouth Atlas study, released today, reveals an expensive lack of progress on reducing hospital re-admission rates:


The readmission rate to a hospital is increasingly seen as a marker of a local health care system’s 
ability to coordinate care for patients across care settings, and readmissions are often a sign of 
inadequate discharge planning and the lack of effective community-based care. CMS has 
estimated the cost of avoidable readmissions at more than $17 billion a year. In hopes of 
decreasing these costs, Medicare plans to reduce payments for readmissions, exposing hospitals 
to considerable financial risks. In fiscal year 2013, hospitals face a penalty equal to 1 percent of 
their total Medicare billings if an excessive number of patients are readmitted. The penalty rises to 
2 percent in 2014 and 3 percent in 2015.


17 billion dollars is a lot of money. There's no one single place or thing we could address that can, with the snap of a finger, fix our health care cost/spending issues. According to the Office of the Actuary, which is part of the Centers for Medicare and Medicaid Services, we spent a total of 2.5 Trillion in 2007 on health care in the United States.

Keep in mind, that 17 Billion dollars is just .0068 of 2.5 trillion...

We have a long, long way to go...


Read the Press Release here...

See the full report here...


Source:

http://www.dartmouthatlas.org/downloads/press/Post_Acute_Care_Release_092811.pdf

http://www.dartmouthatlas.org/

http://en.wikipedia.org/wiki/Health_care_in_the_United_States#Health_care_spending

Good articles from Pittsburgh Tribune Review on health costs...

(For my friends in Pittsburgh)

The cost of healthcare is a well known issue in our overall economy. People like to have tests, procedures, etc. done but we rarely really understand the costs. There's no menu on the wall that explains everything to us like we see in a restaurant. There's no shelves or display cases in our doctor's offices or hospitals to window shop what MRI's, blood work or other tests to compare prices.

Unless you live in France, where they have all this stuff figured out. No mystery for the French.

The Pittsburgh Tribune-Review has some nice articles up over the last few days taking a good look at healthcare costs. In the first, they ask why some procedures cost differently in different locations. In the other, they compare Medicare costs between Pittsburgh and Miami. Pittsburgh has the older population, but Miami spends twice as much as we do.

The problem is too large to ignore. We pay far more for health care in the United States than in any other country and if we really want to fix our national debt issues, healthcare costs and spending will have to be dealt with. Not just politicized.

Here it is boiled down to its simplest form:

That figure, 16% of GDP, reflects only a portion of Americans with health insurance. These other countries, cover everybody at a much lower cost. If you think that our higher expense is justified because we get the best results around, we don't.

I'll update the post through out the week with new articles as they're printed...

Bachmann, Romney have strong showing in GOP debate...

Ok, I've had time to digest tonight's Republican debate and here's some thoughts and my grades:


No one threw any solid shots tonight. All the candidates bashed President Obama at every opportunity. The tactic from Moderator John King of CNN to have the candidates use the honor system with regard to staying within the time limits failed miserably. No shockers whatsoever tonight but several interesting moments.

Mitt Romney: Performed as expected, looked polished and Presidential. Used kid gloves with Pawlenty, stuck to the Party line, played it safe. Got the most questions, but stayed away from controversial statements. I don't know if he acquired any new supporters tonight, but I don't think he lost any, either. Comes off like its his nomination to lose, which it probably is. Doesn't seem prone to unforced errors, he is the anti-Gingrich candidate. Very disciplined performance tonight. (GRADE B+)

Tim Pawlenty: Apparently signed a non aggression pact with the other candidates. Seemed nervous in the first few minutes and bungled his answer about Obamneycare when pressed by moderator John King. The only candidate I heard mention Free Trade but had strong answer citing Obama's mortgage rescue program as a failure. Not as polished or Presidential as Romney appeared. Stated that Sarah Palin is "qualified to be President." (GRADE C)

Newt Gingrich: Had the most work to do tonight but failed to regain much lost ground. His efforts to differentiate himself from the others were either too subtle or simply fell flat. Claimed to be "taken out of context" with his comments about the Ryan Plan for Medicare but then doubled down and said the conversation needed to be slowed down to learn what American really wanted. Scored points on immigration with a call for moderation. Lost points when he said he'd use a loyalty oath for Non Christians. If you're a Gingrich fan, you're probably bummed out tonight. (GRADE C-)

Rick Santorum: Played nice when given an opportunity to comment on Pawlenty's ambitious economic plan. Fear-mongered about the IPAB commencing rationing as soon as 2014. Passed on chance to question Romney's "conversion " a pro-life stance a few years ago. Supports ending the ethanol subsidy. Appeared high strung and tense with his responses. No surprises tonight, but doesn't appear to have the same gravitas as Romney, Pawlenty, etc. possess. I think Santorum is more likely running for Vice President, than the top of the ticket. (GRADE C)

Michelle Bachmann: The most self assured, well spoken, engaging candidate in the debate. Her answers were sharp, contained better content and seemed more powerful to me than those of the others. Announcing her actual (not official) intent to run for office may have been a grandstand move, but it worked. She used it on a question she preferred not to answer, regarding Pawlenty's economic plan. Her quote of former Senator Obama refusing to vote to raise the debt ceiling a few years ago was a nice touch. Her one stumble came regarding the Defense of Marriage issue when she said she'd support an Amendment to the Constitution defining marriage as between a man and a woman, but then said she wouldn't overturn any States that had voted gay marriage into law. (GRADE A)

Ron Paul: God bless Ron Paul. Almost every answer of his contained a plea for attention to the Treasury Department and our currency. No surprises from Mr. Paul at all this evening. Advocates for smaller Government with a Libertarian bent. Feels marriage should be left to the States, if not the Church. Wants the troops home ASAP. I can't identify anything that advanced his cause much tonight. (GRADE C+)

Herman Cain: A little better competition tonight, eh Mr. Cain? Performed well but stumbled on the question about a loyalty oath for Muslims who wanted to serve in his administration. Promised no Sharia Law in America if he gets elected. Supported Federal Government (FDA) retaining role in safeguarding nation's food supply. Thinks the States should decide for themselves on gay marriage, wouldn't overturn President Obama's repeal of DADT unless it was necessary. Also feels that the Constitution should be changed regarding birthright citizenship.(GRADE C)

New Republic: An Old Approach to Health Reform : NPR

New Republic: An Old Approach to Health Reform : NPR

An interesting article by two long time health care experts. In a nutshell, they advocate adjusting our priorities to focusing on quality not quantity of life years. They support targeting a increase of life expectancy to about 80, increasing quality of life across the board with the highest investment being in children, then the adults that basically run the country and finally, seniors over 80 years of age. They believe the government dollars being poured into disease processes that we've shown mostly small advances in don't equal money well or wisely spent. 

Allocating our scarce assets accordingly, they claim would put us on a healthier path to success. It will involve quite a fundamental mind set change of our citizens. Some would call it rationing and therefore evil.

Give it a read, thoughts?

(Thanks to Dave E. for sending me this article)

What's the difference between Vouchers and Premium Support?

  If you've been following the Ryan Plan to change Medicare the last several weeks, you've probably come across this term, "premium support."  It was new to me, and I'm guessing its new to most of my readers. While the Ryan plan has little to no chance of ever becoming law, it will likely remain in the discussion for quite a while. 

 Voted down 57-40 in the Senate today, largely due to the perception the GOP/Ryan plan for Medicare is bad for Seniors, it also played a part in the NY 26th Congressional election yesterday, where a Democrat upset the Republican candidate, for the long time GOP held seat. It will remain as a place holder or an alternative so that the GOP can say, "...look, we've provided a better idea, a better plan. We just need to sell it to the American people and they'll join us in repealing Obamacare." 

  Even if somehow the Senate approved it down the road, President Obama would not be inclined to just roll back his single biggest policy achievement. Not gonna happen.

  Anyway, here's the difference between vouchers and premium support...

  Vouchers are a flat payment to seniors with an amount that's adjusted by the consumer price index. If the index goes up, the payout goes up. If it drops, so does the payout. Seniors would be expected to use this money, sent to them from the Federal Government to buy private health insurance. 

  Premium Support are payments made directly to the insurance companies on the senior citizen's behalf. These amounts are indexed to average health care costs. 

  Its important to note that the Ryan Plan would replace Medicare with a voucher indexed to the consumer price index. For the last 30 + years, health care costs have risen higher and faster than the CPI has risen, by about 4% annually. 

  To add to the confusion, what Congressman Ryan calls Premium Support is really closer to the definition of a voucher system. 

  Over time, if Seniors have to pick up the additional 4% in health care costs, it will be a hardship for that population that have the smallest means to afford the extra expense. For example, the Ryan Plan would give seniors $8,000 in 2022 to pay for their insurance. If for some reasons health premiums rise dramatically, seniors would be stuck paying the difference between the $8,000 and whatever the premiums wound up costing. As the Congressional Budget Office commented, "the share of health care expenses that a typical elderly beneficiary would have to pay out of pocket would go up in 2030—from 25-30 percent under current law, to 68 percent under the Ryan plan.”

  Further, the health care economist who originally designed premium support, Henry Aaron, points to the fact that the Ryan Plan calls for insurance exchanges for seniors and the disabled, while in his and his party's call to repeal the Affordable Care Act (i.e. "Obamacare") which offers insurance exchanges for the younger, healthier and non disabled population. It is much riskier to form an exchange for the worst risk/highest cost pool imaginable. 

  "Vigorous supporters of market-based controls on health spending should start where chances for success are greatest.  That means proceeding resolutely to implement the Affordable Care Act, not repeal it, and to wait for radical change in Medicare until we see how the new system works."

Sources: 

http://healthaffairs.org/blog/2011/04/06/vouchers-or-premium-support-whats-in-a-name/

http://wonkroom.thinkprogress.org/2011/04/07/henry-aaron-paul-ryan-medicare/

Unintended consequences can be painful....

  The State of Working America is an annual report from the Economic Policy Institute. It studies the economic conditions of low and middle income workers and their families. It looks at several different areas, including income, economic mobility, wages, jobs, wealth, poverty, health, and international comparisons. 


  With a great deal of discussion  focused on cutting back entitlement programs, many are calling for less spending in Medicare. Medicare mostly helps the very poor, the disabled, children and pregnant women. This chart shows poverty rates for three groups.  Ages 18+, under 18 and those under the age of 6...

  While abuse is always a target for any large government program and an area that should be attacked vigorously, keep in mind there are consequences, that can be painful. Looking at the groups showing the under 18 age group, cuts across the breadth of Medicaid will likely results in less money for food stamps, health care, education, etc. The increase is visible in all three racial groups, (White, Black and Hispanic.) Its actually children under the age of six that are in the worst shape. Most of the children represented in this chart are likely receiving Medicaid benefits from their States.

  How exactly do children under the age of six abuse Medicaid?

Gingrich infuriates GOP, calls Ryan Plan "Social Engineering"

  I can't know for sure, but I'm guessing Newt Gingrich ruined a lot of GOP-ers Sunday morning. Gingrich knows his way around an interview and make no mistake, he did not mis speak.

 Gingrich, on NBC's Meet The Press show, called the House Republican plan for Medicare, penned by Congressman Paul Ryan of Wisconsin, "right wing social engineering." This comment, unexpected by most, caused Ryan to comment today on a talk radio interview, "...with allies like that, who needs liberals?"

  The former Speaker of the House wasn't done. Gingrich also said he felt the individual mandate is necessary in any health care reform plan. While he did walk that back a bit today by calling it "unconstitutional," the damage has been done. Which was his intent all along.

  With a relatively weak field, Gingrich seems to have thumbed his nose at the entire Republican Party. It forced Ryan and several other GOP leaders to deal with questions about his comments, when they would've rather been focusing on leaning on the White House regarding raising the debt ceiling issue.

  Why did he do what he did?

  I think Newt senses that most of the independent voters aren't Tea Party types. They're fairly mainstream folks who dislike extreme partisanship, of any color. By claiming the middle on the Medicare debate, real or imagined, he now seems like the adult in the room. I'm sure there will be a poll out by the end of the week showing a slight bump in his approval rating. If there is a bump, look for Gingrich to throw unexpected bombs every few weeks to keep the other GOP candidates and the party in general off its game.

  Gingrich has several issues to overcome to obtain the Republican nomination in 2012. His marital issues, his extreme partisanship in the 80's, his extreme partisanship recently where he spoke of Obama being from Kenya, and his lack of discipline overall. He's often thought of as the smartest guy in the room. He's currently thought of as a giant pain in the ass by many fellow Conservatives.

  While Conservatives can't be happy with his comments, Democrats and even President Obama should be thankful. Who would've thought Mr. Gingrich would have sent out Christmas presents early to them? Trust me, his comments from Sunday morning are already in a production studio somewhere being turned into a commercial. Probably several commercials, which we'll see released over the next few weeks/months.

  Game on, guys...


Sources:

http://online.wsj.com/article/SB10001424052748703509104576325350084379360.html?mod=googlenews_wsj

http://www.foxnews.com/politics/2011/05/16/rep-ryan-fires-gingrich-medicare-plan-criticism/

Gingrich Knocks GOP Proposal for Medicare - WSJ.com

Gingrich Knocks GOP Proposal for Medicare - WSJ.com

Criticizes Ryan's plan, supports need for individuals to be required to buy health insurance...

The IPAB: How Will It Change Medicare? - Kaiser Health News

A Q&A on how the Independant Payment Advisory Board will work. Will it mean rationed care for some? Can Obama load the board with all of his Chicago pals?

Let's find out:

The IPAB: How Will It Change Medicare? - Kaiser Health News