Health Wonk Review

This week, Maggie Mahar edits the Health Wonk Review, a biweekly compendium of the best of the health policy blogs.

Voices from the Blogosphere, May 21-June 6

I've decided to let the "Voices" of healthcare bloggers become the theme of this edition of Health Wonk Review. Some are passionate; others are dispassionate; some are disarmingly candid; others are angry.

I'm not going to try to "rate" the posts, or tell you which ones I like. Instead, I want to let you hear those voices, as directly as possible, and decide for yourself.� To that end, I'm quoting liberally from the posts submitted to HWR.

A right to health care?

One of the most provocative entries that I received comes from the Center for Objective Health Policy (COHP), a group that reaches out to medical students while arguing that health care reform violates individual rights.

Nathan Fatal explains: "The problem with [the] assumption" that everyone has a "right to health care … is that a right to a good or service would require that somebody provide it, i.e., that somebody be forced to provide it."

He objects to the individual mandate: "Just as one cannot kick down a neighbor's door and hold a family hostage until all members pay a small fee toward his healthcare costs, a large number of citizens cannot properly hand the role of hostage-taker to the … government in order to exact indirect but forced payments from all fellow citizens … all such actions are the same since they violate freedom of action by initiating force against innocent people in order to provide ‘basic security' to those who ‘need' it."

Fatal also defends the rights of insurers and doctors:

"As Richard Salsman explains in Forbes, health insurance is�'a valuable service provided by intelligent, hard-working professionals . . . people who, like other Americans, … have a right to their own life, liberty, property and the pursuit of their own happiness. Doctors, nurses, hospitals, drug-makers, and health insurers are no more servants of the masses, or even of those in need of health care, than are businessmen, bankers, teachers, journalists, or truck drivers …'"

Supreme Court's ruling on health reform law

Here, on healthinsurance.org, Linda Bergthold also considers the mandate, and suggests that it's "worth reviewing again what's at stake" if the Supremes strike down the entire ACA. She writes:

"We could lose things that have already been implemented" including "free preventive services; children's access to coverage regardless of pre-existing conditions; tax credits for small businesses; and the provision that lets "children under 26 stay on their parents' plan." Meanwhile, "lifetime limits on your insurance plan would probably be reinstated."

If just the individual mandate is overturned, "Most economists and business analysts predict that health care costs would increase, because the uninsured would continue to use the system as a last resort, shifting the costs to those of us who are covered."�But, she notes, "There are a number of ways to get around the overturning of the individual mandate."

Over at the Health Affairs Blog, Alan Weil and Sonya Schwartz each review the impact the Court's decision could have on the states:

Weil writes that "the States' responses" to the ACA "have unfolded in three acts." When the Court issues its decision, "we will see the opening of Act IV. "He offers a "visual representation" of those four acts.

"It is unclear how long Act IV will run," Weil adds. "If significant aspects of the law are struck down, states may have to wait a very long time before it is clear how Congress and the President will respond. States in search of a stable, unambiguous federal statutory and legal environment will almost certainly be frustrated."

Meanwhile, Schwartz grades the possible Supreme Court rulings on a "Richter Scale" of disruption, as she looks at "what each possible ruling would mean for the states that have been most active in implementing the ACA."

"If the Supreme Court invalidates components of the Affordable Care Act, active states will try to adapt to the shifting ground by designing new policies to mitigate adverse selection and cover the uninsured," she concludes. "However, their success in doing so will depend in part on how much the ground shifts."

On Colorado Health Insurance Insider,� Louise explains why Governor Hickenlooper Says Reform Can Succeed Without an Individual Mandate. She agrees that "that if you can make health insurance attractive enough and affordable enough, people will buy it without a mandate." She believes that the generous subsidy program" included in the ACA "should be a significant help."

But if the mandate is struck down, and the provision holds that insurers cannot turn down applicants because of a pre-existing condition, "this could quickly lead to out-of-reach premiums" because healthy people would wait until they were sick before joining the pool. If that happens, she says "the states will have to be creative, and get to work hammering out some sort of carrot and stick program to incentivize people to purchase insurance."

The business of medicine

Over at the Prepared Patient Forum, Jessie Gruman turns from the politics of healthcare to the business of medicine.

Her post begins:

"On Monday morning at 8:30 a.m. the pianist was playing Chopin in the beautiful but deserted four-story lobby of the new hospital where my father was being cared for … the contrast between that lovely lobby and the minimal attention my dad received over the weekend, combined with a report about the architectural ‘whimsy' of a new hospital at Johns Hopkins ("a football-field-size front entrance" with ‘manicured gardens and a rectangular water feature') make me cranky."

Why do hospitals indulge in "conspicuous spending" on amenities that the truly sick cannot possibly appreciate, while accepting "staff shortages" (nurses checked her father just once each shift) and "dangerous medical errors"? Gruman:

"We should probably just grow up and recognize that our na�ve notions of the beneficence of health care generally and hospital care specifically are outdated … Health care is big business" and "these new fabulous facilities and all this advertising constitute the cost of … competing for private payers."

Cancer, too, has become a big business. On Health News Review, Gary Schwitzer critiques the media hype surrounding news of an experimental cancer drug.

"When the New York Times reports something, the TV networks are soon to follow," Schwitzer observes. "So when the Times reported ‘A new class of cancer drugs may be less toxic,' featuring a single patient's experience with T-DM1 ��NBC followed closely – featuring the exact same patient in the exact same setting."

"One woman out of 1,000 in the trial. Who chose her?" asks Schwitzer. "The drug company PR people? "

By contrast, Schwitzer calls USA Today's piece "refreshing."�He offers "Excerpts:

2nd sentence: ‘The experimental drug, T-DM1, doesn't cure anyone.'"Later: ‘… statistically, it's possible that those findings could be due to chance, Horning says.'"

Roy Poses, founder of Health Care Renewal� also questions how the quest for earnings affects healthcare, zeroing in on the for-profit hospice industry:

"Remarkable public comments by some for-profit hospice marketers show their focus on increasing patient volumes, even if that means recruiting patients who are not really at the end of life."

Poses explains that this means that some patients suffering from "acute illnesses and injuries may not receive … treatment" they need, while profit-driven hospice care "ends up shortening their lives."

"It's funny that the people who were so alarmed by ‘death panels' do not seem so alarmed by this pathway to denying care for profit," Poses observes.

Rising costs of Medicare and Medicaid

Meanwhile, on Managed Care Matters, Joe Paduda compares how fast the costs of Medicare, Medicaid and commercial insurance have been growing.

"Medicare and Medicaid trends are looking better these days" he writes. "And this trend looks like it will continue. Note this is per-capita growth, which is more accurate when comparing different payer types."�But he reports, "employers' health care costs are up 5.9% this year, and would have increased more if not for a significant increase in cost-shifting to employees (up over 19% from 2011 – 2012)"

Giving physicians a check-up

But money does not drive all of the problems in our health care system � at least not among doctors � writes Brad Flamsbaum in Why We Lie�on the The Hospitalist Leader.)

Doctors sometimes fib, Flamsbaum acknowledges, to insurers, in order "to obtain pre-certification for patient testing perceived as necessary"���and, yes, they lie to patients: "We are humble folk and he says, physicians have the same foibles as the flock we oversee."�Yet, "it's not about the money," he explains, "but a host of other factors ���surprisingly more potent than financial rewards."

Flamsbaum points to research on why humans lie that begins with our "ability to rationalize," followed by "conflicts of interest," "creativity," "previous immoral acts," and "being depleted," all illustrated here.

On�Health Business Blog, David Williams expresses his own�concerns about physicians. �He quotes a doctor advising that�doctors should be candid with families�and "raise the issue of a grim prognosis early on," giving them "an opportunity to deal with it." Otherwise families may fall victim to "optimism bias."

Williams is "wary." The Physician may be "wrong, or unduly certain." He realizes that doctors "must find ways to deal with death" or "they can't practice medicine. But … I don't want a physician to make peace with my relative's death … while he's still alive."

By contrast, Michael Gavin and Mark Pew, executives at Prium, a worker's comp utilization company, worry that�doctors are too quick to give injured workers a heavy dose of pain-killers. �Writing on Evidence-Based, they point to "A new ruling from Texas … that finds payers liable for a range of opioid-related side effects ranging from addiction to death. Prediction: This is just the beginning."

Finally, over at�The New Health Dialogue, Joe Colucci and Shannon Brownlee turn to�how television depicts physicians. "The Fox show House ended last week," they write. "It was entertaining, but as far as health policy is concerned, we're not sorry to see it go … Dr. House exemplified the "cowboy doctor" as "hero" who is in fact a "hazard" … practicing "reckless, unscientific, non-evidence based medicine."

Just "one point in House's favor: he works with a team" and they "actually talk to each other … Unfortunately, that's as unrealistic as the rest of the show."

Thoughts on obesity

In another post,�The New Health Dialogue's�Colucci examines New York Mayor Mike Bloomberg's most recent public health proposal,�banning sugary beverages�"gigantic enough for a small marine mammal to do laps in." Bloomberg would limit sodas served in restaurants to 16 ounces.

"The reaction has included furious opposition from �people claiming this is the nanny state run amok," Colucci reports, but in fact, "There is extensive evidence from psychology and behavioral economics that people respond to larger portions by eating more."

Over at 365 Days of Wellness, Kat Haselkorn focuses on a different profit-driven problem. In Unstoppable Obesity Epidemic, she acknowledges that "obesity is a bigger issue in low-income communities and is more likely to affect minorities." But "marketing and advertising play a significant role in childhood obesity, nudging children towards processed foods and sugar. Government subsidies allow Big Agriculture and top manufacturers to aggressively market products to children … 77% of obese children become obese adults."

Uninsured veterans

The government might better be spending that money on Veterans. On the Healthcare Economist, Jason Shafrin's Memorial Day post�reports that "About 10 percent of U.S. veterans under the age of 65 lack health insurance and are not being taken care of by the VA."�Eligibility for VA services "is based on veteran status, service-related disabilities, income level, and other factors," Shafrin explains. "Proximity to VA facilities and cost-sharing requirements" also affect access.

High anxiety

On Workers' Comp Insider, Julie Ferguson reports on another group at risk. The "boom in cell phones has spawned" a huge demand for radio towers, and "brutal" schedules are leading to more fatalities among tower workers. �(See this video from a prior post.)�"Tower work is carried out by" layer after layer of subcontractors, she explains allowing large companies to "deflect responsibility for on-the-jobwork practices." In an era of sub-contracting, "this layering makes OSHA enforcement almost impossible."

Electronic health records

Jann Sidorov focuses his concern on Electronic Health Records (EHRs)�and "The Need for Legal Framework." Writing on Disease Management Blog�about a piece in the Economist that examines the need for legal reform for military drones and driverless cars, �Sidorov argues that "since robot-like artificial intelligence is involved in electronic health records, the same legal protections may be necessary there."

Age rating

Although I'm a fan of health reform, I too, have my worries. Under the Affordable Care Act, insurers can charge older Baby-boomers (in their 50s and early 60s) premiums three times higher than they would charge a 20-year-old for exactly the same coverage.

I explore the issue here, on HealthInsurance.org, where I've recently begun posting. (Soon, I�ll be re-launching HealthBeat thanks to technical assistance from HealthInsurance.org. In the future, I�ll be writing on both web sites.)