Plan B?

If can’t get fixed in time, how about hiring enough call-center capacity to get the job done?

I’m so old …

[voice from the audience: How old are you?]

… why, I’m sooooooo old that I remember, back before the Good Lord gave us websites, we had things called “call centers” where banks of telephone operators took phone calls and consummated transactions. That was a big improvement over making people come in to physical offices.

So if - once again - a contractor f’d up an IT project and we can’t get working in time, what would it cost to hire enough call-center capacity to get the damned thing done between now and the end of the year?


1. Recall that Obamacare was supposed to be a state-run program, with the federal exchange just a backup for states too dumb or stubborn to do it themselves.  As far as I can tell, the state-level programs are mostly working fine. This ought to teach voters a lesson about voting for teahadi politicians, but probably won’t.

2. I’m more than willing to believe that the WH and HHS blew this one by not paying close enough attention. But go ahead: you try to run a big software project through federal procurement under a hard deadline, and come back and tell me about it.

Contracting-out can be a fine idea. It can also be, and often is, a recipe for disaster, especially when the underlying bureaucracy has been so hollowed out that it can’t do the appropriate monitoring and supervision.  Paradoxically, an agency needs to be stronger and better-managed to run a contracting-out system than it does to do things in house. Of course heads should roll over the rollout, but it’s harder to make heads roll when the guilty parties aren’t on your headcount.


Will BCBS California’s proton beam therapy decision stick?

Austin Frakt with news of Blue Cross Blue Shield of California deciding not to cover proton beam therapy for prostate cancer because it is no better than other options, but costs more.

Will this stick? By that, I mean that my experience in talking about health care cost control is that most people are all for it in the abstract-while being opposed to just about anything that has a chance to work. And push back seems inevitable. Continue reading “Will BCBS California’s proton beam therapy decision stick?”

New Class: Future of Medicaid in North Carolina: Charge & Questions

I am very excited to be teaching a new Masters of Public Policy course this Fall at Duke University on The Future of Medicaid in North Carolina. The 14 students all have background in health policy, including prior job, coursework and recently completed internships.

The charge to this class is going to begin with the charge that the recently passed North Carolina budget gives to a new Medicaid Reform Advisory Group ( p. 161-62): Continue reading “New Class: Future of Medicaid in North Carolina: Charge & Questions”

In a nutshell

Barack Obama, yesterday: “The one unifying principle in the Republican Party at the moment is making sure that 30 million people don’t have health care.”

From the President’s press conference yesterday:

The one unifying principle in the Republican Party at the moment is making sure that 30 million people don’t have health care.

True. And potentially powerful. The current lunacy of the GOP is not politically sustainable. The question is when the public becomes sufficiently aware of that lunacy that even “Red” districts come into play. The answer I’m hoping for is “2014.”

Relative Value and journalistic values

Medical price-setting is a scandal. So is the way the WaPo deals with being beaten by the Washington Monthly.

Saturday’s Washington Post runs a long story - breathlessly labeled “Exclusive” - about the Relative Value Update Committee, an AMA venture that effectively sets the prices Medicare pays for medical procedures. The committee meets in secret and consists entirely of people who represent those with direct financial stake in the outcomes. (Not, of course, including patients or taxpayers.) Fox, met henhouse.

Astoundingly, the Federal Advisory Committee Act, designed precisely to prevent this sort of abuse, doesn’t apply, because - even though the results of the committee’s deliberations are almost always accepted by CMMS, the group isn’t technically an “advisory committee.” That’s because it it’s run by the AMA rather than by the agency. Given how thoroughly FACA screws up the process of getting outside information to federal decision-makers, to find that it doesn’t apply in the case where it most needs to apply is pretty scandalous.

And, while we’re on the topic of scandalous behavior, take a look at the story on precisely the same topic by Haley Sweetland Edwards in the current Washington Monthly, which showed up on line about three days ago. Continue reading “Relative Value and journalistic values”

Obamacare’s Success in New York is in Part a Testament to the Insanity of the Policy that Preceded it

Obamacare’s success in New York was greater because of the failure of prior policy

Fans of Obamacare are cheering the massive drop in individual health insurance premiums in New York State. But it should be acknowledged that Obamacare looks so good in the Empire State in part because the health insurance policy that came before it was so bad.

Sarah Kliff helpfully details New York’s prior health insurance law:

For years New York has had one of the most heavily regulated insurance markets in the country. The 1993 reforms not only required insurers to accept all customers; they also mandated that insurers charge everyone the exact same price. Young or old, healthy or sick, it doesn’t matter in New York: Everyone gets the same deal.

No doubt this policy was an applause line for politicians: We will make the mean, rich insurance companies pay for everyone’s healthcare and not let them have the income stream that would make such coverage sustainable. You won’t need to buy insurance until you are really, really sick and then the fat cats will have to sell it to you cheap and pay all your massive health care costs! That’ll show ’em, right? Wrong:

New York has, for 20 years now, been a long-running experiment in what happens to universal coverage without an individual mandate. The result: a small insurance market with very high insurance premiums.

New York’s prior law highlights one of politicians’ worst impulses, which is to allow the private sector to have control of some domain and then try to suspend resultant market realities through legislation. If the health insurance companies in New York had not jacked up premiums in response to having to cover all applicants at the same price, they would have gone bankrupt.

Obamacare fixes the problem by being realistic about how markets work. Private companies can provide health insurance for everyone and make a profit doing so (The model in several Western European countries) but only if everyone has to enroll. This was for years a Republican talking point against New York State-style popular-but-economically-crazy health insurance regulation; I myself first heard it at a pre-Obama American Enterprise Institute seminar.

But Obamacare’s appreciation of what markets can and can’t do in the health insurance domain came from within Democratic ranks with no Republican support. Substantive health care policy debate is now something the liberal wing of the Democratic Party engages in with the moderate wing of the Democratic Party because the Republican Party, sadly enough, has largely abandoned the field.

Medical Care, Medical Training and Financial Incentives

Two new essays in Washington Monthly examine the inbuilt financial advantage of medical specialist reimbursement and residency training

Phil Longman, author of a coruscating book on the Veterans Health Administration has penned an extended critique of the current system of U.S. medical education. He questions the return on investment from the federal dollars that academic medical centers receive to train the next generation of physicians:

[Residency] programs turn out too many specialists who go on to practice in places where such doctors are already in oversupply, and where, according to numerous studies, they often inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment. Meanwhile, residency programs are producing a dwindling number of primary care physicians and other generalists, who are already in chronically short supply in most parts of the country and are desperately needed to implement the kind of reforms to the health care delivery system necessary to improve its quality and efficiency.

Longman believes that putting conditions on the medical training subsidy is a good way to force residency programs to train more primary care docs. I agree with much of what Longman says, but doubt that this is where the public policy leverage truly resides. The preference of many aspiring doctors-to-be and academic medical centers for specialist training has little to do with the subsidy for residency training and a lot to do with specialist care being reimbursed at a much higher rate than primary care. Until that is changed, tinkering with the comparatively small amount of money that is devoted to medical education ($19 billion) is not going to motivate much reform in a three trillion dollar health care system.

I raised this in a friendly email exchange with Longman, and he helpfully directed me to another essay on this very point in the same issue of Washington Monthly. In it, Haley Sweetland Edwards makes the case that the reason why specialist care is so much more richly compensated than primary care is simple: The reimbursement rates are set by a Medicare advisory committee composed largely of specialists.

Overprescription of Opioids Would be a Problem Even if Addiction and Overdose Did Not Exist

Over-prescription of opioids is a public health problem that goes well beyond overdoses and addiction

A number of commentators have unhelpfully framed debate about the astonishing rate of opioid prescriptions in the U.S. (more annual prescriptions than adults in the entire population at this point) as a “war” between those who care about preventing addiction/overdose and those care about reducing pain for patients in need. From this vantage point, any attempt to reduce or even question the number of opioid prescriptions is an attack on people in pain, another front in the heartless drug war, evil cops interfering with angelic docs etc.

This framing is medically and scientifically wrong, as New York Times reporter Barry Meier points out in this interview. Prescription opioid overdose and addiction are currently huge problems in the U.S., but even if they weren’t, the indiscriminate prescription of opioids would be dangerous to public health. Opioids typically have a miraculous effect on acute pain, but this does not necessarily translate into chronic pain relief, particularly as tolerance sets in over time. Indeed, a least some opioid users became hyperalgesic, i.e., they experience more rather than less pain.

This is not the only line of scientific findings that flies in the face of the assumption that if opioids are used less often, more pain will be the inevitable result. In a study my colleagues and I conducted with surgery patients (first author Dr. Ian Carroll; publication here), the amount of time individuals stayed on opioids after surgery, surprisingly, bore no relationship to their level of pain. People stay on opioids for a range of reasons not necessarily linked to pain; in our study taking them for long periods was well-predicted by pre-existing depression, for example. Many people who are on these medications would be in better health and equal or less pain if they were weaned off them.

A further dangerous side-effect of long-term opioids is hormonal, as Meier explains:

These drugs have a very powerful impact on our production of sexual hormones — testosterone in men and estrogen in women. Lower hormone production is not just about growing hair or sexual performance; it’s about your entire energy level. These drugs are depleting people of energy. There are even data showing that the more powerful opioids, the long-acting OxyContin, methadone, fentanyl, which is sold as Duragesic, have an even more powerful effect on depressing hormone production than short-acting opioids.

What Meier is saying will come as a shock to those who foment over-simplified policy debate about opioids, but will not be surprising to pain medicine specialists. Although that field has a few extreme voices regarding opioids, for the most part pain management experts are already doing what the rest of the country needs to do: Trying to find the right balance between the benefits and costs of these drugs rather than declaring them horrible or flawless.

Reflections on Deinstitutionalization

Harold Pollack offers an acute analysis of the effect of deinstitutionalization in his latest Washington Post piece. Many commentators have pronounced the policy a blanket success or a complete failure, but as Harold points out, it’s more complex than that:

On the whole, deinstitutionalization improved the lives of millions of Americans living with intellectual and developmental disabilities (I/DD) — albeit with many exceptions. These policies allowed people to live with proper support, on a human scale, within their own communities. Second, deinstitutionalization was far less successful in serving the needs of Americans suffering from severe mental illness (SMI) — again, with many exceptions.

The vision of the community mental health movement was that institutionalized individuals would be moved to the least restrictive possible residential setting. They would prosper, and the rest of society, by having more regular contact with them, would become less fearful and stigmatizing. This happened some of the time, but as Harold argues it was more common for people I/DD. In contrast, people with SMI were more likely to end up with marginal or no housing and few needed few support services.

I agree with his analysis, but would add one gloss about the standard by which we judge the effects of deinstitutionalization on people with SMI. The heartbreaking sight of a raggedly-dressed man with schizophrenia screaming at shadows on a windy street corner is not by itself proof that deinstitutionalization was bad policy. Year after year in place after place, government audits and investigative journalism reports found widespread abuse, cruelty and inhumanity in state mental hospitals.

If we assume that the pitiable man with schizophrenia on the corner would be in a high-quality, safe, well-staffed state mental hospital if only the country hadn’t deinstitutionalized, we are inventing a past that rarely existed. Granted, it may bother the rest of us more that someone is sleeping in their own waste on the street than when the same thing happens in a back ward of an institution, but that’s because only in the former case do we have to look at such suffering, not because the person themselves is necessarily worse off.

Misprojecting the Impact of Expanding Insurance for Addiction Treatment

The Affordable Care Act will allow addicted people far more and better treatment options than they have today

Michael Dhar and Christie Thompson have both been doing some serious, long-form reporting on how the Affordable Care Act will affect addiction treatment. Both of them asked me a question based on what I consider a misinformed Associated Press story: What does it matter that the ACA gives millions of people insurance for addiction treatment when current services are often overwhelmed with too many patients?

The AP looked at current, underfunded services for uninsured addicted patients and observed quality and access problems. Fair enough. But AP then drew a questionable conclusion: That newly insured patients will go to these same, overwhelmed, underfunded treatment programs, thereby compounding the current shortage. That’s a bit like interviewing people in an overstretched food bank on the eve of a new government program that will give every family $200 a week to spend in restaurants and concluding that the food banks are going to be overwhelmed by the new program.

The AP analysis underappreciates the dynamic nature of the U.S. health insurance and health care systems. Health care providers want to make money. When millions of people gain insurance for some medical condition as will happen under the ACA, providers expand services to capture the business. The overstretched public sector programs for uninsured addicted patients profiled by AP might very well have fewer rather than more patients after the ACA goes into full effect. That’s because there will be more care options available for addicted people, including outside of the public sector. And as for the widespread quality problems in addiction treatment, the growth of insurance coverage is good medicine because addicted people will have more health care options than they do now, creating an incentive that currently doesn’t exist for treatment quality improvement.