Watching Rachel Maddow recount the views of many Republican candidates who emerged from last night’s primaries, I realized that most of you, younger than I, grew up taking the right of a woman to choose for granted. But the current crop of Republican candidates for the fall elections does not. Many of them believe a woman should have to bear her child even after a rape. Most don’t believe in abortion for women with serious illnesses.Their goal is 100% live births. And one of them believes in convenant marriage — no divorce ever. (Although I don’t always agree with Rachel Maddow, I have learned to trust her research.)

But you are not outraged. And that’s because you don’t seriously believe this right will be taken away. To you, it was always there.

Let me tell you a story.

Just after I graduated from college, I was working at a publishing company and Carol, the girl at the next desk, with whom I used to eat lunch, got pregnant by a married dentist. This was in the “Mad Men” days, and it was an overwhelming situation from which I distanced myself, having no counsel to offer. She wasn’t even a good friend, just an office buddy.

And then she told me she had arranged to get an abortion in New Jersey, and she asked me to come with her. I said yes, because although I never imagined that I, a “good little girl,” would ever be in that position, I felt sorry for her. Meaning I was glad it wasn’t me this time.

We had to take the subway to a place where we were picked up by a “nurse” and driven to a place we were not allowed to see the outside of. We were driven around the back. No one even gave us the address, just the directions. We were both young, about 21, and we were terrified.

When we got inside the dark building, they took Carol away from me into a back room. I waited, afraid to breathe. When she came back, she was pale and silent, but stoic. She was so proud of herself, and she thought she had made the married dentist happy. He paid the bill, although he wasn’t there, in cash up front.

We got back on the subway, and Carol began to bleed. She bled all over the subway, all the way home. By the time we got off, she was almost too weak to stand, and we got in a taxi to her house. I was freaked out. I had no idea what to do. She called the dentist to ask what to do.

She did not die, but it was very close. There was no 911, so I called the hospital nearby. They told me what to do for her, and said she should come in. They took her in, and I went home, terrified, and told my parents.

Days later, Carol came back to work, depressed and miserable. Soon after, I went back to graduate school, where I forgot about it all until I got pregnant myself nearly ten years later. And then, although I was not married either, and the father of the child still was, I had the baby. And became an abortion rights activist. Just seeing someone have an illegal abortion made me one, even though I never had an abortion myself.

Years later, when I was a foster mom, my sixteen-year-old foster child got pregnant. I marched her down to Planned Parenthood, where they gave her the “morning after” pill. I never even asked permission of the agency that licensed me. I had seen enough. She is now a mother herself, but at age 26, and she still thanks me for taking her to Planned Parenthood that day.

Life is complicated, women. Protect your rights. Believe me, you won’t want to be without them.

Until the 1970s, most medical care was primary care. Certain primary care doctors were known to be better at diagnosing things than others, and if you thought something was really wrong and your own doctor couldn’t figure it out, you went to a diagnostician. While these talented people may have charged a bit more, I don’t remember it being 5x or more, as a visit to a specialist costs today.

As medicine became more and more influenced by technology, however, it quickly became more specialized.  That’s why HMOs were founded: to keep people out of the offices of specialists. HMOs used primary care providers as gatekeepers to specialists,and unless you were referred to. a specialist by your PCP (Primary Care Provider), you couldn’t go.

Sick people stared over the gate at the coveted “specialists,”  feelIng denied and rejected by an uncaring system. Eventually, enough of them sued or voted with their wallets and the HMO system collapsed. Without the gatekeeper, people descended In hordes upon the specialists, who were only too happy to receive them, having been nearly bankrupted by the HMOs.

And that is how we got here–to the place where an under exercised and overfed population has lost the will and the ability to care for itself and goes trotting off to the specialist to treat the problems caused by–themselves: their obesity, lack of conditioning, sleep deprivation and prescription drug dependence. The specialist radiates, operates, and medicates, turning what should have killed us evolutionarily into “chronic conditions” that cost 19% of the GDP to control.

Not only have we lost the will to correct our behavior, we have also become unwilling to be penalized for those costly conditions. How dare they raise my insurance premium or tell me I am too old for a liver transplant or a hip replacement?

And now comes the backlash. Here come the studies that finally prove the new cancer drugs don’t really work better than the older ones and the cardiac surgery doesn’t prolong life, followed by the indications that too much salt, or too much fast food, is the cause of it all.

And here we come back to the concept of the family doctor, now perhaps renamed the ” medical home,” whose job it will be to give you the same advice your mother used to give: get enough rest, go out and play, eat your vegetables.

Good luck finding a primary care doctor as the culture shifts back to the pre-eminence of prevention and the control of costs. The past two decades have driven them almost to extinction, abandoned to the “specialist” with his bag of pills and black box of scans. All the technology finally leads us back to the same conclusion: it’s cheaper and easier to prevent illness than to cure it. We change the oil in the car and run the virus scan and the spyware filter. Now we have to set up maintenance contracts with ourselves. As a culture, we can’t afford to trade in these bodies, like “cash for clunkers.”

They didn’t use those words, but that’s what they’re saying, nevertheless. There are two principles at stake here: First, that discrimination against sick people is a thing of the past; and second, that the days of cherry-picking insured groups are over.

Either insurance companies can get on board, or else they are begging for Lynn Woolsey’s newly-revived public option to become the law of the land. They certainly appear to be crying out for one. Here are a couple of stories that prove the point:

Insurers stop writing policies for children

This story could likewise be headlined “Insurers throw hissy fit, kick and scream on the floor, choose those least able to defend themselves as targets.”

Nothing screams public option like screwing kids. Via MSNBC:

Some major health insurance companies have stopped issuing certain types of policies for children, an unintended consequence of President Barack Obama’s health care overhaul law, state officials said Friday.

There’s nothing unintended about it. It’s purely the mean-spirited choice of insurers to lash back because they are about to be subject to laws which tell them they may not discriminate against people who are sick, or who might become sick sometime in their lifetime. It’s neither a consequence, nor unintended. It’s a sick, petty power game.

The administration reacted sharply to the insurance pullback. “We’re disappointed that a small number of insurance companies are taking this unwarranted and unnecessary step,” said Jessica Santillo, a spokeswoman for the Health and Human Services department.

Starting later this year, the health care overhaul law requires insurers to accept children regardless of medical problems — a major early benefit of the complex legislation. Insurers are worried that parents will wait until kids get sick to sign them up, saddling the companies with unpredictable costs.

The major types of coverage for children — employer plans and government programs — are not be affected by the disruption. But a subset of policies — those that cover children as individuals — may run into problems. Even so, insurers are not canceling children’s coverage already issued, but refusing to write new policies.

That bold part in the middle is pure, unadulterated horse dung. Insurers aren’t worried. They’re behaving like two year olds, trying very hard to resist the inevitable — an end to pre-existing conditions.

Their lobbyists might possibly be the biggest concern trolls that roamed this planet, eclipsing even Fox News and Elisabeth Hasselbeck in their phonied-up concern.

“Our plans are very concerned about this,” said Alissa Fox, a top Washington lobbyist for the Blue Cross Blue Shield Association. “If the law says that insurers have to take you any time, any place, some people will see that as an opportunity to wait until their children get sick to buy coverage.“

Insurers work hard to insert creative accounting rules into medical loss ratios

Medical loss ratios are pretty simple. Add up the costs to provide ACTUAL medical benefits against the money received in premiums and investment income. What is spent must be at least 80% of what came in. If it’s more, insurers have to rebate the difference.

80% is generous. Medicare’s MLR is 93% by comparison, and that 7% covers administrative costs only. Insurers were given an additional 17% leeway.

So when the New York Times reports this:

At stake, according to a report issued Thursday by Health Care for America Now, a coalition that supports the new law, is hundreds of millions of dollars when the law goes into effect next year. If the six largest for-profit insurers had had to meet the new standards last year, they would have been required to refund $1.9 billion, the coalition said.

The insurers contend that the advocates are discounting the value of an array of programs aimed at helping patients, which should be considered an aspect of quality improvement as part of the 80-cent minimum.

No. Not really, and let’s be honest, brokers’ commissions, expensive retreats, and “experimental programs” which can mean anything from weight loss initiatives to new computer/paperwork tracking software is really not part of the MLR.

These insurers need to be made to understand clearly that if Medicare operates on a MLR of 93%, they can manage with 80% and clear, understandable rules. It’s a very bright line: Medical claims costs versus receipts. Period. End of discussion.

If they do not understand that, Lynn Woolsey has an answer for them, and every deficit hawk in Congress: A public option will take care of their concerns. Parents can sign their kids up for one, be confident that the MLR will not have any creative padding, and there will be no discrimination against people with pre-existing conditions.

So what’s it going to be, Blue Cross/Blue Shield, United Health, Anthem, WellPoint, and the rest of you? Are you going to live within your means or are we going to force that ONE THING YOU FEARED MOST down your collective throats? Make no mistake, it can be done.

Behave like children, expect the adults to treat you like children.

cross-posted to Crooks and Liars

President Obama’s HiTech Act, enacted right after he took office, should produce a major transformation in American health care when it gets going. Along with the health care reform legislation that was dragged kicking and screaming through Congress last spring, the Act could put the planets in alignment for real change in the way care is delivered and paid for, and the way patient outcomes are achieved.

The HiTech Act specifies that every American should have an EHR (electronic health record) by 2014, and receive continuity of care through a regional Health Information Exchange. It even provides coverage for Geek Squads to help providers with the transition to EHRs: finding vendors, deployment, and identifying specific ways to advance care in their own practices. A first set of rules for what constitutes “meaningful use” of these information technology tools has just been released. So things are getting moving to give both patients and providers the information to make better health care choices. But…

These programs always sound good. For example, one new federal program, Beacon, looks at health system change at a community level in a group of demonstration communities, The communities that have been chosen as Beacons have already achieved a high level of EHR adoption and want to find out how they can use the information these records generate to improve health care. The stakeholders in these communities will come together, identify goals, and unleash a range of strategies in service of these goals.

But the programs requires the coming together of four largely separate tribes of crusaders for improvements in health care:

1) Quality improvement fanatics who want fewer accidents and bad outcomes in hospitals
2) Payment reformers who want to change reimbursement from volume to value
3) Consumer energizers who want consumers to be more involved in their own care, and to be given better information
4) Health IT evangelists who want to unleash futuristic tools and applications

For any of this to work, all these tribes have to work together, combining their perspectives and tools.

Fifteen demonstration communities with baseline high EHR adoption rates have already been chosen as Beacons. They’ve already been working through questions such as What do you want your community to look like in three years? Which patients do you want to achieve what outcomes (for example, care coordination for asthmatic children using range of Health IT tools to prevent hospitalizations)? And how do you measure whether you are getting anywhere?

Geisinger, one of the Beacons, is working through the process to get its outcomes identified first, then measures, then tools, then sustainability of its goals. It is trying to extend its best practices outside its boundaries.

It’s a laudable goal to deploy information technology in service of specific payment reforms and clinical reforms. What are the odds that this will succeed, however? Many people have broken their picks on the hard rock of true health care reform.

Because the American health care system is so broken, I’ve been on a lifelong journey to avoid it. The obvious path is through disease prevention, an aspect of practice in which allopathic medicine is particularly wanting.

I have been long aware that there is a science of psychoneuroimmunology (interactions between the nervous system and the immune system, and the relationship between behavior and health), but today I had a chance to hear about some placebo-controlled, double-blind, gold standard (the kind MDs routinely demand) immunological studies that demonstrate the interconnection between the mind, the body, and the immune system beyond a shadow of a doubt.

When I entered the room, late to the beginning of the lecture, the speaker was telling the assembled group that the biggest single predictor of an early death is an external locus of control. In other words, if you are not perceiving yourself as in control of your own life, you will die sooner. In a related study, researchers found that attitude about aging predicts how long a person will live. A positive attitude–aging gracefully and accepting the aging process– extends life 7,5 years longer than gains made either by either lower BMI or smoking cessation.

At Stanford University, women with metastatic breast cancer who were given group therapy lived eighteen months longer, and with a better quality of life than their control group, left to deal with their disease without support. In another study, it was found that a mother’s optimism about her pregnancy and her own life lowered the incidence of pre-term births and low birth weight babies.

All of this is part of a larger recent emphasis by medicine on the importance of the immune system. Where previously scientists thought everything in the body began in the brain, which sent signals to the rest of the body, the new theory is that everything in the body starts with the immune system, which releases pro-inflammatory cytokines that alert the brain to illness and signal the brain to be tired and shut down other systems, leaving more energy to fight the invader.

So not only are you what you eat, apparently, but you are also what you think. Pessimism triggers the release of negative chemicals, which if released over and over again, shut down the brain. According to Candace Pert, PhD, the neuroscientist and pharmacologist who discovered the brain’s opiate receptors, there is even a physical place in the brain for belief.

Thus, the goal for a long healthy life is to keep positive, optimistic, and in control. But that’s easier said than done. Food — or rather nutrition — is a good starting point, as psychological states that present as depression or anxiety can actually be due to nutritional deficiency.

There’s a long list of nutrients that are known to lift depression. Three of the best-known are Folic acid, a B vitamin; tryptophan, the chemical in both turkey and milk that makes you fall asleep; and Omega-3 fatty acids, in fish like salmon. Complex carbohydrates (fruits,vegetables and whole grains) are known to lift serotonin levels that control whether you feel depressed.

All of this is a complicated way to say that fruits and vegetables prevent disease. Along with limiting the stressors in your live (or at least the way you respond to them), a good diet can actually prolong your life and keep you out of the doctor’s office

The Rand Corporation recently completed a comparison of 2000 different health policy scenarios and concluded that the Patient Protection and Affordable Care Act provides health insurance coverage to the largest number of people while keeping costs as low as possible.

That’s a remarkable conclusion from an organization that isn’t known for bias toward policy decisions made by Democrats.

Some specifics:

The study examined how the expected outcome of health care reform would have changed if components of the law were structured differently. For example, would more people receive coverage if companies with fewer employees were required to provide health insurance to workers or pay a penalty? And how might the cost to the federal government change if the income level for Medicaid eligibility was raised to a higher level?

Researchers simulated more than 2,000 different policy scenarios using the RAND COMPARE microsimulation model, which was designed by RAND to provide independent analysis about how different reform proposals would impact the American health care system.

The analysis found that only a few policy scenarios would produce better results than expected under the new health reform law and those scenarios represent only small improvements over what will be expected by 2016.

For example, the RAND analysis found that an additional 4 million people would be insured with no additional cost to the federal government if the penalty for individuals who fail to purchase health insurance increased to $1,200 annually per person (from $750 in the law).

The analysis also showed that a combination of strategies could cut federal spending by $20 billion annually without decreasing the number of newly insured. But this would require a combination of measures that would place a higher financial burden on the lowest-income segment of the nation’s population.

Rand also concluded that the alternatives were not likely to survive the political process:

“These alternative strategies strike us as politically challenging, if not untenable,” McGlynn said. “On balance, the new law appears to have landed on a distinctive plain of the policy frontier where the costs and coverage levels achieved were reasonable enough to secure passage of the law.”

This is the overlooked fact of health care reform. What passed is what could pass. We can have arguments until the cows come home about what should pass, or what the ideal is, but what we have is what was legislatively possible. In fact, I’d argue it was right on the edge of what was legislatively possible, especially when considered in light of the tight vote margins.

The Obama administration has not received much credit for actually achieving a goal progressives have held dear for 100 years or more. Whether this relates to disappointment over the compromises needed to secure passage, or idealistic expectations remains to be seen. The fact remains, this administration managed to move legislation through which was the absolute edge of what COULD be done. For that, they should be congratulated.

Rand Corp. Press Release

It’s amazing how health care reform, a burning issue six months ago, has fallen off the radar (unless you are sick). Nevertheless, Congress did enact something at the end of all that fighting, and pieces of the legislation will begin to go into effect this month. If you have a family, are self-employed, aging, already Ill, or employed by a small company, you might want to mark your calendar for the dates some of the changes take effect.

As of now: insurance companies can’t drop you if you get sick. Known as “recession,” this was probably the worst part of the old system and it should be gone by now, because all the insurance companies have agreed to stop this practice before it becomes mandatory by law do so.

Small businesses that offer health insurance can start taking a tax credit in 2010, too. This lasts until 2013.

June: Temporary access to Insurance for people with preexisting conditions: Ninety days after the enactment of the legislation, on June 21, 2010, there should be a new program that provides access to insurance for individuals with preexisting conditions who have not had insurance coverage for at least six months. This high risk pool will be available until 2014 when the exchanges come on line. Watch carefully for how much the premiums will cost, and remember that you have to had been uninsured for six months to be eligible.

Also this month businesses that carry retirees on their health insurance will receive government subsidies for 80% of the cost of those premiums, up to a cap of $15,000, So don’t listen to all the griping from corporations about the cost of retiree health insurance. Those costs are shifting to the government.

July: Health and Human Services is required to have a web site with information about what plans are available in each state for individuals and small businesses. Unfortunately, you probably won’t be able to understand this information until next March, when rules for how to present the information in a format that allows for easy comparisons will take effect.

September: the law will prohibit plans from excluding coverage for preexisting conditions for children until the age of 19. and children can stay on the family policy until they are 26. This happens September 23.

Also in September look for coverage for immunization and prevention services with no co-pays.

And here’s a big one: starting in September health insurance companies will have to report how much of your premium they spend on your care. This will be available on the internets, and must be 85% if you are in a large company plan and 80% for small companies and individuals. Behind the scenes, the lobbyists are wildly trying to help write the rules for what counts as care. This is a slimy business right now because it directly affects the insurance company’s profits.

Don’t tune out on all of this now, because the devil is in the details and although you may have gone on to worrying about the oil spill and the financial reform, you can be assured the health industry lobbyists have not. They are still hard at work trying to undermine reform even more assiduously.

One of the provisions in the health care reform law passed in March says insurance companies must use 80% of the premiums they collect to provide actual health care– meaning, to pay claims. What a concept. Unfortunately, as the regulations for the legislation are being written in Washington, the same lobbyists who tried to stop the law completely are now trying to game it by affecting the definition of what constitutes paying a claim.

According to Forbes,

The legislation says that 80% of what’s collected by insurance companies must be spent to pay medical claims. This number is what’s known as a “medical loss ratio” or MLR. If the 80% MLR target is missed, rebates are to be given to the insured members. The problem is: what counts as a medical claim? What if you are running a program to encourage people to exercise? Could that be counted? What if the flu season is light this year but heavy the next? Should members get rebates in year one but the HMOs go broke in year two? (Yes, is probably the response from lawmakers.)

So the plans are trying to get all kinds of internal expenses counted as medical expenses, and hoping to obfuscate the reporting requirements, so when you shop for health insurance, you won’t be able to pick the plan that spends the most money on you, the customer.

Part of this is investor pressure. Investors want low medical loss ratios. If a company has to spend more than 80% of its revenue on you, the customer, otherwise known as the expense, it doesn’t look as profitable to investors. On the other hand, it is your premium dollar, and in theory you’re entitled to it.

Who will this impact the most? Individuals and small businesses, of course.

If you want to get really mad, you can download Sen. Jay Rockefeller’s letter to Secretary of Health and Human Services Kathleen Sibelius, in which he formally tries to explain this to her as she supervises the writing of the enforcement regulations, here. Rockefeller says consumers should be able to understand and shop for the plan with the most dollars spent on its members.

Forbes thinks that this will result in HMOs that look more like utilities, with highly regulated businesses that are closely scrutinized. And what, exactly, would be wrong with that?

At lunch yesterday, I was the guest of a group that contained several retired physicians. We listened to a talk by a board member from a large non-profit local hospital system. The speaker, knowledgeable and well-prepared, talked about the cost drivers of health care in America, which he listed as an over-reliance on technology, the practice of defensive medicine because of law suits, heroic measures at the end of life, lack of transparency as to the true cost of procedures, non-standard reimbursements, and a few others.

He pointed out that while we might have reformed health insurance, we had done little to cut costs, because we hadn’t changed the delivery system. And he went on to say that we had to move toward outcomes-based medicine, which he thought would convince doctors to prescribe fewer MRIs, mammograms, and other procedures that had proved to have little effect on patient outcomes.

During the discussion that followed, the comments from the physicians were not at all what I expected. Many were heated but not over the need for higher reimbursement, more tort reform, or loss of power to insurance companies.

No, instead they said we would never reduce costs until we taught physicians to make a diagnosis by taking a complete history and talking to the patient, rather than by opting out and scheduling tests. They said the art of diagnosis has all but vanished from medical school teaching and that students don’t know the simple principle of looking first for horses when hear hoofbeats, and not for unicorns. To these men, the race to adopt new technology hasn’t made the practice of medicine better, it has merely made it more expensive. Many of them are still reading their grandchildren’s X-rays to make diagnoses younger physicians miss. These guys saw diagnosis as an art, now a lost art. Many med students don’t even know how to listen through a stethoscope. Perhaps that is because doctors don’t get paid much for listening.

Personally, I think the introduction of DRG (diagnosis related group) codes has done as much as anything to discourage the art of diagnosis. A DRG code is generated after every patient visit, and allows the doctor to get reimbursed. More complicated codes get higher reimbursements, and some medical staff assign codes according to the profit motive, while others simply code incorrectly out of ignorance. But the standardization of patient codes turns every patient into a statistic. Might as well pick a code that approximates what the patient might have and give him/her some tests instead. The doctors also pointed out that their colleagues who are still in practice will not give up their MRIs easily, because they are in the habit of relying on them, and even tort reform won’t change that.

Health care reform isn’t over.  For patients, it has just begun. The health plans are beginning to figure out how they will survive and thrive under the new rules, and the way forward is, according to one managed care exec, to change how providers are paid. This will have consequences.

Jeffrey Kang, MD, chief medical officer for Cigna, has some thoughts on this already:

It’s important to measure and provide incentives for better outcomes… not for improved processes or certifications achieved.  Some examples of outcomes to measure might include smoking cessation, weight loss, lower blood pressure, and lower total cost of care.  Incentives should be around pay-for-performance…not for shared insurance risk.

“We as health plans are better off continuing to hold that insurance risk because we have the actuaries and the capital,” he says. Health plans can then focus on “really trying to create payment methods that give people incentives to improve quality, lower cost or penalties if they miss these targets.”  Cigna has eight pilots offering incentives for quality, outcomes and lower total healthcare costs.

As for wellness and disease management, Kang notes, “From a benefit design perspective, the legislation did get it correct” by focusing on first dollar coverage for prevention and screening.

Cigna should be one of the thought leaders in this aspect of the reform, because they were around 25 years ago when this was tried before under the term “health maintenance organization.” The HMOs (disclaimer: I did the marketing for one of the first) thought that if they could keep people healthy, they could lower the cost of care.

They tried everything. They held classes, they provided patient education films and leaflets,  they put up big posters in doctors’ offices. None of it worked.

Finally, they “capitated” the doctors. A doctor received $X per patient per year, whether he saw that patient once or one thousand times. A patient had to be seen by a PCP (primary care physician) before he could make an appointment with a specialist.

Capitation was supposed to be a way to quell rising costs and encourage doctors to keep their patients healthy. But doctors resented being gatekeepers and fought back by refusing to participate in some HMOs, and the patients responded by rising up in hordes to protest lack of access to care. During this period, if your employer changed plans, you likely had to leave your doctor.

Buoyed by patient support, some doctors began backing out of  capitated HMOs altogether, and employers began to buy a new product: the PPO — a plan where the patient could choose the doctor, and there were fewer gatekeepers. That’s how patient choice got to be such a big issue in the last health reform debates. Patients learned that under an HMO they couldn’t choose which doctor they wanted to see, but had to see a doctor in their plan.

Never mind that most patients couldn’t choose a doctor wisely in their wildest dreams, especially while sick.

This time around, we have marvelous sources like HealthGrades and Yelp, two services that further distort the process of patient choice through advertising or subscriptions.

Cigna took a lot of flak the last time around for being a horrible HMO. So, by the way, did Kaiser. This time, executives of both are emerging as thought leaders in the cost control space.

I hope we don’t go through the same thing we went through in the 80s. It could have been wonderful (yes, I’m biased because Intergroup, the HMO I worked with, started with pure motives) but it ended up dreadful. And we literally can’t afford to have that happen again.