Bush and Kerry, healthcare foes (warning – this link will give you the latest Kondracke column – thus if you are reading this in the future, you will have to search back through his columns to find this particular column).

If you or a loved one suffers from cancer, heart disease, diabetes or another dread disease — or you fear you might contract one — you have a hard choice when you vote for president this year.

President Bush is cutting the budget for medical research that might find a cure for your disease. At the same time, the Democratic frontrunner, Sen. John Kerry, D-Mass., wants to strangle the revenues of the pharmaceutical companies who’d develop a medicine to treat you.

Between the two of them, they’re a deadly duo. And Sen. John Edwards, D-N.C., would be little better. He’s joining in his party’s jihad against drug companies.

The remainder of the article argues that Bush is worse because of the proposed NIH budgets.

Disclaimer: I receive NIH funding and AHRQ funding.

Wow, this is a really tough issue. I am reminded of the famous George Bernard Shaw quote (often attributed to Winston Churchill) – “We’ve already established what you are, ma’am. Now we’re just haggling over the price.”. We know that we cannot increase the NIH budget by 100%. Our challenge is to understand how much we should increase that budget.

Supporting the NIH is akin to motherhood and apple pie. One can always stand on the high moral ground when criticizing the President’s NIH proposal. The question becomes not the NIH budget per se, but the NIH budget in the greater context of the overall budget.

I would love to see NIH increases and AHRQ increases. Our research group would have better funding odds. Our fellows would more likely have successful research careers. And even more important, our contributions (and the contributions of similar groups around the country) would improve our overall health status.

Read the article and perhaps you can decide (just on this issue) whose approach would benefit the common good. I fear that I cannot tell.

I often rant that each party has good and bad proposals related to health care. This article reinforces my beliefs.

Congress is wrong

2 Cancer Drugs, No Comparative Data – this title is misleading, because the drugs are really anemia drugs, used both with cancer patients and with Chronic Kidney Disease patients.

Medicare officials sought the study, hoping to see if Aranesp, a drug made by Amgen that costs about $1,300 a vial, is superior to Johnson & Johnson’s Procrit, an earlier version of the drug that costs $470 a vial. The federal Medicare program spends more than $1 billion a year on the two drugs, which stimulate the bone marrow to produce red blood cells in patients who have become anemic during treatment for kidney disease or cancer.

We (physicians) have no way to choose between two similar drugs (and these drugs are just variants of each other) unless we have head-to-head comparisons. I have repeatedly ranted on this subject. For physicians to control pharmaceutical costs, we must do the right studies. The study which CMS wants is the right study. Congress should not prevent important medical research.

I hope that we can overcome the pharmaceutical industries meddling so that we can do good comparative studies. Interestingly, the health insurance industry wants these studies. Thus, the Republicans have two major support groups at odds over this provision.

I hope that Congress revisits this issue. Perhaps this article and more like it will help everyone understand the importance of doing this type of research.

Costs and benefits

This article does not explicitly address medical issues. However, I believe it does a nice job emphasizing the costs of any benefit. One can take these principles and apply them to malpractice suits, drug benefits, marijuana laws, and many other issues that we address regularly. Goodies cost us

There are no two ways about it: There are benefits from all the costly federal, state and local regulations imposed on American businesses. But we must also acknowledge our federal, state and local regulatory agencies have no jurisdiction in India, China, Southeast Asia and Latin America. That means for many products and services, people who are far less productive than we, in a physical sense, can beat us in the global marketplace.

We all can agree there’s no benefit that’s worth any cost. If that weren’t true, we’d do nearly anything that has a benefit, and that would include mandating a 5-mile-per-hour speed limit. Why? The benefits would be enormous in terms of the tens of thousands of highway fatalities and injuries avoided. We don’t have a 5-mile-per-hour speed limit because we have decided its benefit is not worth the enormous cost.

No free lunch. Someone has to pay.

Is the new Medicare bill flawed?

Or how inconsistent our politicians are. This column documents the Democrats’ inconsistency on Medicare. I am not implying that the Republicans are any better when it comes to the political process. Patient welfare will always remain secondary to political gain. Medicare hypocrisy

What’s wrong with the new Medicare bill? Nothing that a little honesty couldn’t cure. A recent Wall Street Journal article suggests that the problem is not so much the substance but the failure of Republicans to rise up in defense of the measure. Since the day the bill was passed, Democrats, labor unions and seniors from retirement villages have been holding rallies and press conferences to scream about how the law is either “scamming” seniors or cheating them out of more generous private-sector coverage in order to pay off “Big Pharma and insurance companies.”

They are also annoyed that the drug benefit only pays for half of all drug costs and begins two years from now — not immediately. They want the pharmacy benefit management companies in the law to be replaced by Medicare price controls and a national drug list. Some disgruntled Republicans aren’t helping matters much by saying “I told you so” after learning that the Bush administration’s estimate of adding a drug benefit to Medicare exceeded the Congressional Budget Office (CBO) number by more than 25 percent.

To paraphrase Mark Twain, let’s get the facts straight and then distort them as we please. As an article in Health Affairs reports, the president “proposed an outpatient prescription drug benefit to be offered under a new voluntary Part D of Medicare … Medicare would pay half the cost of covered drugs ? The drug benefit would be administered by a [private] pharmacy benefit manager.” To help seniors maintain more generous private-sector coverage, “the president’s proposal had incentives for employers to keep [drug coverage]. Medicare would pay employers 67 percent of the premium subsidy costs it would have incurred if retirees had enrolled in Part D instead.”

Sound familiar? This proposal was supported by virtually every Democrat. But it wasn’t President Bush’s plan; it was Bill Clinton’s. And it had three big differences. First, it was scheduled to kick in four years after it was to pass in 1999, not in two as the Bush plan anticipates. Second, it covered a lot fewer people. And third, the Clinton plan didn’t cover catastrophic drug spending; it capped government spending at about $2,500 per senior with some adjustment for inflation. The Bush plan covers all drug costs over $3,000 a year.

I hope you read that excerpt and the remainder of the article. The Medicare bill is flawed. Virtually every bill passed by Congress is flawed. We can always find and exploit the flaws.

What we should (and apparently never will) do is to evaluate the pros and cons and weigh them to decide on whether a bill is worthwhile. I believe that on the whole (the forest view) this is a good bill. If I focus on trees, of course I see some that should be cut down.

Frist on Democrats working to change the Medicare law

Frist Expects Congress to Try to Expand Health Coverage

Dr. Frist, a principal architect of the new law to provide prescription drug benefits to the elderly, accused Democrats of waging “huge campaigns to discredit” the law. He expressed concern that their criticism might sway voters.

“Democrats right now are out banging this thing and using very partisan criticism, trying to tear it down, because they see that it is a huge leap forward,” Dr. Frist said.

Mr. Bush takes credit for adding drug benefits to Medicare, a goal that long eluded Democrats. But Democrats are determined to turn the issue to their advantage by highlighting what they see as defects in the law.

“This is an opportunity for Democrats, but they must seize it and work to define the terms of the debate,” says a memorandum for Congressional Democrats by Al Quinlan, president of Greenberg Quinlan Rosner Research, a political consulting concern. “It is critical to engage aggressively and not allow Bush and the Republicans to shape the dialogue.”

To win the debate, the memorandum said, Democrats should “define the current law as unacceptable, not as something that can be fixed.” Though “voters start with a slight inclination to support the law,” it continued, they swing decisively against it when they are told that Medicare beneficiaries will face high out-of-pocket costs, high drug prices and gaps in coverage.

I worry that the politics of health care will undermine real progress. The Democrats do not seem to care whether this law helps some patients. They will not admit that having a drug benefit, even with some gaps, trumps having no drug benefit.

They see any law purely for its political ramifications. But then the Republicans are no different here. Politics trumps the common good at all times. In years past, the Congress and Senate understood compromise. The two parties worked together to at least try to craft positive legislation.

The Medicare bill is not perfect. But then neither am I, or you. Frist is right that we should watch what happens for a year or two prior to making more radical change (because this law is radical change).

Why John Edwards scares me!

Yesterday I linked to Sydney Smith’s piece on Edwards. One of my most frequent commentors – Bernie – had this to say:

I read the article you linked to and it had lots to say about defensive medicine as a consequence of malpractice litigation and little to say about Senator Edwards’ supposed misconduct as a malpractice lawyer. Unless you assume taking malpractice cases is prima facie evidence of moral depravity, I have yet to see how any of these opinion pieces impeaches Senator Edwards’ character.

Bernie and I often disagree – and we both give and take arguments well. I really have not problem with his character, rather his apparent philosophy scares me. Rangel has a great post on this – How Edwards and his ilk are destroying America Quoting from Rangel-

Despite such manipulation of the court system, as repulsive as it is to rational, thinking Americans who have a sense of fairness and justice, a surprising number of people feel that this kind of behavior is perfectly acceptable as long as there is a sense that some type of “justice” has prevailed. This mentality goes along with the commonly held idea that things are not supposed to go wrong without someone else being responsible for causing it. This is a mentality that trial lawyers like Edwards have successfully cultivated over the last 40 years. Americans are more suspicious about big government, big business, industry, and professionals like their own physicians. If something goes wrong then someone is to blame. Call the lawyer!

Obviously, physicians and lawyers view the world through different prisms. (Well maybe not all lawyers, but likely most trial lawyers). These prisms differ due to a fundamentally different motivation for our professions.

Physicians have the patient’s well being in mind as a first priority. We “adjudicate” information to try the best known therapy for our patient. We espouse evidence based medicine as our goal. New studies change our practice (the recent data on HRT represents a study which has caused a sea change).

We often will consult a colleague if we believe that the colleague can add valuable insights into our patient’s care.

The job of the trial lawyer is to win the case for his/her client. Some lawyers take cases to change policy. But most cases are chosen for monetary benefit. The underlying principle is to win.

There are exceptions to this generalization, however, it is not the lawyer’s job to worry about the health care system. He/her will often put the client’s interest above the greater good. That is the nature of the lawyer/client relationship and of trial law in this country.

I believe that lawyers like John Edwards undermine our medical system. They can ignore data, science and greater good, and they do regularly. They are doing their job – and Edwards does that job well.

I admire his skill, but I disdain what his cases do to our health care system. I do not blame him, but I do not want someone with his attitude about the law as my president.

We need tort reform, and not just in medicine. With Edwards in power any hopes of reform would vanish. The court system, as used in this country, does not protect the public good. It does not evaluate the scientific evidence as scientists do.

We need a change, and since Edwards represents the current sorry state of affairs, he scares me.

As predicted, we have not heard the last of the Medicare bill

Despite New Law, the Fight Over Medicare Continues

Democrats, denouncing the arm-twisting tactics used to pass the bill in the House, vowed Monday to rewrite the law to reduce the role of private health plans, to increase drug benefits and to authorize the government to negotiate drug prices.

Unless we elect a Democratic majority in the House and Senate, I doubt that they will get their wish. I would like to see some slack in negotiating drug prices. It sure works for the VA system.

A plus for the Medicare bill

Our legislative process has great flaws. The bills they construct make a camel look normal. Almost any observer can find flaws with any bill. Each bill contains something which makes great sense.

Most of you know the expression – there must be a pony in here. Perhaps this is the pony. Rural Doctors Welcome Medicare Overhaul

The Medicare bill before Congress contains help for rural health care providers that would significantly strengthen service in those areas, hospital administrators and doctors say.

The centerpiece of the huge Medicare bill is a prescription drug benefit for older Americans, but the measure also would boost payments to doctors and hospitals in rural areas by $25 billion and rework a reimbursement system they say is outdated.

“The bottom line is that there have been some very damaging provisions in Medicare for many years for the way rurals are paid, and this erases most of them,” said Dr. Wayne Myers, president of the National Rural Health Association.

The government has used different rates in rural and urban areas to determine the size of checks sent to hospitals that treat Medicare patients. The formulas date to the 1980s and were based on the belief that medical treatment is less expensive in small cities and towns.

Many lawmakers and hospital administrators say that no longer is the case as hospitals everywhere compete to recruit doctors and pay the same for high-tech equipment.

“The costs (in rural areas), believe it or not, are also very high, and in many cases higher than in cities,” Sen. Max Baucus, D-Mont., said on the Senate floor Friday.

The bill reduces the extent local wages factor in the formula that determines what a hospital gets paid from Medicare, which would raise the reimbursement rate in rural areas, said Myers, a former official with the Health and Human Services Department’s office of rural health policy.

It also would eliminate a provision that set the hourly rate of a rural doctor lower than an urban doctor’s for cost-reimbursement purposes; raise payments in regions that are short on physicians; and increase how much rural hospitals can be reimbursed for treating uninsured patients.

These provisions have great importance. They are long needed and very welcome. Keep searching, there may be more ponies.

The Canadian approach to marijuana

I agree with this editorial. O Canada, O cannabis

The Medicare Bill

This is a bill that everyone can (and will) criticize. If you are interested here are some links with selected quotes. 6 Democratic Candidates Attack Medicare Measure

“This is a Trojan horse bill,” General Clark said. “It’s got provisions in it to undercut Medicare. I think the American people want their representatives and their association to stand up and be counted for senior citizens, and that means rejecting this bill.”

The debate offered a hint of the fault lines likely to emerge as Democrats struggle to position themselves on an emotionally charged issue that carries great weight with their constituents. The bill includes provisions intended to inject market forces and more competition into Medicare, which Republicans say will lead to better, more cost-effective care. Many Democrats condemn such efforts as tantamount to privatizing the program.

But the bill, which would create the largest transformation of Medicare in its 38-year-history, would also significantly increase spending on the program and offer a prescription drug benefit that many Democrats had sought for years.

Incremental medical repair

Conservative lawmakers who were balking over the bill said it did not go far enough in the direction of true privatization reform to yield the kind of savings that would make it more affordable. Liberals, such as Sen. Ted Kennedy of Massachusetts and several Democratic presidential hopefuls, think it goes too far, sticking the nose of privatization under Medicare’s tent that they warned would eventually destroy the fee-for-service nature of this virtual government monopoly.

In a stunning political split among the Democrats this week, the powerful 35 million-member AARP (which lobbies for America’s retirees) embraced the GOP’s compromise. AARP policy director John Rother said he was won over by the added subsidies the bill would give low-income Medicare patients, plus incentives aimed at keeping employers from abandoning existing drug coverage for their retired workers.

Endorse Medicare

On the liberal side of the ledger, USA Today notes that “Sen. Edward Kennedy, D-Mass., and other critics are denouncing parts of the new plan as a $12 billion slush fund for private insurance companies to lure seniors out of traditional Medicare. But they offer few alternatives other than open-ended spending.”

But conservatives are no better when they claim that an experiment falls far short of real reform, since the time limit dooms the proposal to failure. They forget that in 1996, welfare reform legislation,whichMr. Kennedy also strongly opposed, was offered as a five year experiment requiring re-authorization. What conservatives did was to insure that welfare reform worked and when re-authorization time came, to improve and refine the policy.

Medicare Monstrosity

Instead, Republican negotiators, joined by Democratic Sens. John Breaux and Max Baucus, went behind closed doors and decided to use the public’s demand for drug coverage as an opening wedge to change Medicare. The shame of it is that Republicans and Democrats in the Senate had already reached a real compromise. The bipartisan proposal, crafted in cooperation with Sen. Ted Kennedy, was inadequate. Yet it was better than this bill. It passed the Senate overwhelmingly because it left the larger Medicare issues open for real debate later.

But House conservatives weren’t willing to go that far. They want medical savings accounts, a tax cut for the wealthy in disguise, and they insisted on experiments with privatization.

But if privatization is such a good idea, why do the private insurance companies need such big subsidies to enter the Medicare market? The bill includes $12 billion for what Kennedy calls a “slush fund” to subsidize the private insurers. That’s not capitalism or competition. It’s corporate welfare.

The debate is interesting. The Democratic candidates have sided with Ted Kennedy in attacking the bill. The NY Times (not known as a conservative bastion) has endorsed the bill. AARP (which many consider pro Democrat generally) has endorsed the bill. Everyone dislikes something about this bill. This bill is clearly a compromise. So I leave you with two quotes about compromise:

A COMPROMISE is the art of dividing a cake in such a way that everyone believes that he has got the biggest piece. (Ludwig Erhard – a German politician)

The COMPROMISE will always be more expensive than either of the suggestions it is compromising. (Arthur Bloch)

NY Times endorses Republican Medicare plan

Wow! Medicare for the Fiscally Healthy

ith the government wallowing in deficit spending, it is understandable and even encouraging that Congressional Republicans are thinking about requiring high-income retirees to pay more for their Medicare coverage. This rare nod toward fiscal reality arises as the G.O.P.-led Congress attempts to deliver on campaign pledges to provide a Medicare prescription drug program.

Legislators are looking for ways to soften the financial blow of the 10-year, $400 billion drug plan now on the table. This page has questioned whether the country can afford to add new entitlements to Medicare at all, given the size of the federal deficits swollen by the Bush administration’s ill-advised tax cuts. If Congress is intent on going ahead, there will certainly have to be other savings made.

Many Democrats, but not all, warn that the Republicans are venturing onto sacrosanct ground in proposing such a basic change in Medicare, a highly popular program that has always been equally available to all retirees.

But upper-bracket Americans have enjoyed disproportionate benefits under the Bush tax cuts. They can easily afford to pay the premium increases being considered for the top 2 percent of beneficiaries: individuals earning over $100,000 a year, and couples more than $200,000, in retirement. Even the possible tripling of annual premiums, to roughly $2,100, for the richest retirees would still make Medicare a bargain.

Well said, and correct logic!!!

NY Times on the health insurance crisis

The Health Insurance Crisis

Even most experts were surprised by the sharp jump in the number of Americans lacking health insurance last year. The latest Census Bureau figures show that the number of uninsured jumped by 2.4 million, the largest increase in a decade, bringing the national total to 43.6 million uninsured in 2002, or 15.2 percent of the population. The ranks of the uninsured have increased by 10 percent over the past two years, with the likelihood that things may get worse this year.

The lack of health insurance, a problem once confined mostly to the poor and nearly poor, has reached into the lower middle classes, most notably to those earning $25,000 to $49,999 a year, and even to some above $50,000. It is a problem that needs to be addressed by Congress and the administration, which have thus far sat mostly on the sidelines.

Several factors are driving the expanding crisis. The number of unemployed Americans keeps growing in this jobless recovery, thus depriving many people of the opportunity for employer-provided health insurance. Even many full-time workers ? an astonishing 20 million last year ? lack health coverage.

Many employers, both large and small, are cutting back on the health insurance they provide, either by dropping it entirely or by making it harder for employees to qualify. Some are requiring much higher contributions from workers, so many workers are dropping coverage rather than paying amounts they consider unaffordable.

Underlying the problem is the still-unsolved issue of escalating health care costs, which leave employers struggling to find a way out and individuals staggered by premium increases.

The NY Times takes the easy road – let big government provide a solution. As usual, those who favor big goverrment show little understanding of the crisis, they just want Congress to solve (put a bandaid on) the problem.

Health care costs may or may not be escalating out of proportion. We must relate cost to value. We need to understand where the money goes.

Health care costs increase for many reasons. Some costs increase because newer technology makes diagnosis more reliable. More reliable diagnoses allow us to better target therapies.

Some costs increase because new medications allow us to improve quality of life or even quantity of life. Some costs increase because patients demand more care. Some costs increase because the cost of doing business increases: government regulations always cost money, malpractice insurance costs, higher salaries for employees (supply and demand for nursing staff).

So the question we should ask as a society is what health care we want, and is it worth the money? Should we expect health care expenditures to increase or not? Can we develop more reasonable governmental regulations? Can we control liability costs?

Solving the health insurance problem should require a careful analysis of all costs. We should better understand why health care costs increase every year.

Unfortunately, I am skeptical that Congress will address this issue intelligently. They rarely show common sense when passing laws which have impact on health care. Why should we expect better now?

The stalled Medicare bill

Besides Prescription Drugs

MEMBERS OF CONGRESS are pretending that the Medicare bill, currently bogged down in conference negotiations, is simply about prescription drugs. Not quite. Both House and Senate versions of the bill contain provisions designed to help particular companies and congressional districts, benefiting everyone from Weight Watchers International to marriage therapists to doctors in Alaska. The legislation also contains measures to shore up rural health care, adjust doctors’ pay and patch up bits of the Medicare system that don’t work. And it has new rules allowing the re-importation of prescription drugs from Canada and elsewhere. Some of these measures are justified, some not.

The most expensive provision in the House bill would create “health savings accounts” — in effect, tax shelters. While it is a good idea, in principle, for people both to save for health care costs that health plans don’t cover and to manage some of their health-care money themselves, this is an extremely expensive program. The cost to the budget is more than $170 billion over 10 years, which comes on top of the $400 billion that the bill is already going to cost — and this at a time of soaring budget deficits. The creation of costly health savings accounts should be considered as part of a fundamental restructuring of health care, not tacked on as an afterthought.

Regular readers know that I favor health savings accounts. I would like to see a tighter linkage between the patient and health care cost decisions. While I have written often about this concept, Robert Prather – Insults Unpunished – has written even more often. For a feel for this issue check out – Health Care Costs Yet Again.

I believe that the Washington Post has this issue wrong. In the meantime, I do not expect any compromise on these issues. We will go another year with politicians dancing their dance. And our single payor system for the elderly gets more unfair to both patients and physicians.

Fat as a political issue

Political Debate Looms Over Obesity

Even fat is the stuff of politics in Washington. And with obesity a growing health problem, lawmakers, lawyers and activists are lining up the way they do for most issues: on two sides.

The left’s view is that the food industry and advertisers are big bullies that practically force-feed people with gimmicks and high-calorie treats. They say Ronald McDonald is the cousin of Joe Camel.

The right’s argument has been dubbed: You’re fat, your fault. They say people can make their own choices about food and exercise.

“I don’t think people want to go back,” says Tomas Philipson, a University of Chicago economist. “They’d rather be fatter and richer.”

The debate has spilled over into public policy, with proposals for a junk-food tax, limits on food advertising, demands for more details on labeling and lawsuits against food manufacturers. Several states are considering limits on sweets sold in schools; Some are debating whether to force chain restaurants to list nutrition information on menus.

Sen. Mitch McConnell, R-Ky., recently introduced a bill that would prevent people from suing restaurants and food manufacturers for making them fat. Similar legislation has been introduced in the House.

The stakes are high. Some 300,000 Americans die prematurely each year from being overweight. It’s the leading lifestyle-related cause of disease and death in the United States after smoking.

Apparently, the obesity lawsuits captured political attention. As a libertarian, I believe that each individual must take responsibility for his/her own actions. Thus, I cannot support suing over obesity. The article seems balanced and presents both sides.

Wow!!! Congress considering a logical proposal

Back from my beach hiatus, I browse the NY Times quickly and find! Congress Weighs Drug Comparisons

Over fierce resistance from the drug industry, Congress is moving to authorize research that systematically compares the effectiveness and cost of top-selling prescription drugs.

Proponents say that if Medicare is to spend $400 billion on new drug benefits over the next 10 years, it should have objective, reliable information about which medicines are most effective.

“Often there are a number of competing drugs to treat the same condition,” said Senator Hillary Rodham Clinton, Democrat of New York, a leader of bipartisan efforts on the issue. “But which is more effective? Oftentimes we just do not know.”

The House voted last month to provide $12 million to the Public Health Service to conduct “research on the comparative effectiveness” of prescription drugs. The money was in an appropriations bill for the fiscal year that will begin on Oct. 1.

Drug companies say they fear that such studies will be used to restrict patients’ access to medicines perceived as too expensive. But supporters of the research say it will improve the quality of care. Doctors, patients and insurers need help in making informed choices, said Representative Doug Bereuter, Republican of Nebraska.

Representative Nancy L. Johnson, Republican of Connecticut, said the proposal was “absolutely key to reducing the cost of drugs.”

“There are many expensive products on the market that are no better than aspirin,” said Mrs. Johnson, the chairwoman of the Ways and Means Subcommittee on Health. “We need to be able to demonstrate that and provide senior citizens and all Americans with that information so they can choose the most cost-effective, medically effective pharmaceutical for their particular needs.”

Researchers said they might address questions like these: How does Lipitor stack up against Zocor for lowering cholesterol? How does Prilosec compare with Protonix for ulcers and heartburn? How do the long-term effects of Vioxx and Celebrex compare with those of older drugs for arthritis, like Motrin and Naprosyn?

Mrs. Clinton and Representatives Tom Allen, Democrat of Maine, and Jo Ann Emerson, Republican of Missouri, have proposed spending $75 million on comparative studies by the National Institutes of Health and the federal Agency for Healthcare Research and Quality. The studies would focus on drugs widely used by Medicare and Medicaid beneficiaries.

Mr. Allen said, “Our proposal would ensure that doctors and patients have credible, unbiased information, as an antidote to the claims made in so many pharmaceutical TV commercials.”

As expected, the pharmaceutical companies oppose this plan. Their rationale is incomprehensible.

With studies comparing various drugs, federal officials could make “simplistic, one-size-fits-all decisions about which patients should have access to new medicines,” the industry said.

The Pharmaceutical Research and Manufacturers of America also made these arguments:

¶The federal studies would almost surely influence private insurers. “As a result, the government’s cost-based decisions about medical access would be imposed on many patients in both public and private health plans.”

¶Cost-effectiveness studies show which drug works best, on average, for large numbers of patients, but the studies often overlook the value of specific medicines for individuals or subgroups, like racial minorities. “Different people need different medicines” because they respond differently.

¶Federal studies could stymie “incremental innovation.” The government often does not appreciate the value of the incremental benefits of a new drug over existing treatments, but a series of modest gains can produce a major improvement ? a much safer, more effective medicine.

Sometimes an idea makes great sense. This idea fits that category.

Washington Post on Medicare

Medicare Robbery

But the conference now is faced with the need to square the square, keeping on board both Senate Democrats who want to spend even more money and House Republicans who want an even bigger role for the private sector. A few weeks ago, all players involved were talking optimistically of finishing the conference by the end of this month. Now some are talking about September — or later. Myriad squabbles will doubtless break out over precise numbers, levels of benefit and how much cash should be spent to encourage private insurers, who, so far, have shown little interest in participating in any of the new roles the bill designs for them. Lobbyists have persuaded Congress to add on a wealth of provisions, benefiting groups ranging from rural ambulance services and Alaskan doctors to the weight-management industry. They will no doubt try to add more.

Yet behind the squabbles lurk deeper issues. Of these, perhaps the one that has received the most attention is Medicare’s universality. Many Democrats and some Republicans consider this to be Medicare’s central attraction. It is a program, they say, that gives the same benefits to everybody, rich or poor, and therefore receives universal political support. To preserve this universality, many are fighting against a provision in the House bill, for example, that calls for people with incomes above $60,000 to pay a larger share of their drug bills. They object on the grounds that nobody should be treated differently.

This kind of thinking helps to illustrate what has gone so deeply wrong with the bill, a piece of legislation that seems to be oblivious to its long-term consequences. In practice, the refusal to countenance any means-testing will set in motion a vast transfer of wealth, from the pockets of America’s poorer children — who will eventually be working adults — to America’s wealthier elderly. The desire to maintain political support for Medicare is understandable, but the zealous opposition to any reform that would provide fewer benefits for the rich is profoundly misplaced. It guarantees the swindling of a generation that cannot vote in order to benefit a wealthy constituency that can.

I agree with the Washington Post. I should not receive the same benefit as someone with little retirement income (I assume that my retirement savings will provide a better than average lifestyle). We should help the needy, but getting older does not necessarily imply neediness.

Will we have a Medicare bill?

I would guess not. The current bills are huge, technical and significantly different. It appears that House Republicans and Senate Democrats are digging in their heels. Compromise Seen as Harder to Find on Medicare Drugs

Differences between the Senate and the House bills have become more apparent in the two weeks since the competing versions of the legislation were adopted. Now conservative House Republicans and Senate Democrats are issuing ultimatums, threatening to oppose the final legislation if it does not address their concerns.

…

Many Republicans say such competition is essential if Medicare’s costs are to be brought under control. But Democrats say the competition and the higher premiums could be devastating to the oldest and sickest beneficiaries, who are most likely to stay with the traditional program.

…

The Senate and House bills have significant similarities, often overlooked in the debate over the most contentious provisions. Both bills are officially estimated to cost $400 billion over 10 years. Both rely on private insurance companies to deliver drug benefits under Medicare, starting in 2006. Both call for drug discount cards, to help the elderly in 2004 and 2005. And both increase Medicare payments to doctors and hospitals in rural areas.

Much of the recent maneuvering is simply an effort to lay down markers for the approaching negotiations. But nobody is sure how much is positioning and how much is nonnegotiable principle.

“The question is: what is the deal killer in the Senate, and what’s the deal killer in the House?” said a House Republican strategist. “It’s not clear what the walk-away point is for either side. It’s just not clear.”

I would like to see a good bill. But my limited observation does not suggest that either side has a good bill. I believe that an error of commission would harm us more than an error of omission. We do not need a bad bill. We have enough of those already.

Tort reform unlikely

I think the Democrats just get too much money from the trial lawyers. Short of Votes, Senate G.O.P. Still Pushes Malpractice Issue

A bill that would impose strict limits on jury awards in medical malpractice cases ? a central element of President Bush’s plan to revamp tort law ? appears headed for defeat in the Senate. But the majority leader, Bill Frist, intends to introduce the measure on Monday anyway, forcing a vote that could be used against Democrats in the next election.

The bill, similar to one the House passed in March, would limit awards for pain and suffering to $250,000.

The bill has no Democratic sponsors, and Republican leaders, including Dr. Frist and Senator Mitch McConnell, the Republican whip who will manage the bill on the floor, concede they do not have the 60 votes needed to overcome a filibuster.

“It’s going to be difficult,” Mr. McConnell said.

A vote could occur as early as Wednesday. But proponents say that even if they lose, as expected, the issue is not dead for this Congress.

Instead, Dr. Frist, who has made malpractice changes a signature issue, hopes the vote will force lawmakers to take a stand. That would expose them to more pressure from lobbyists, and might yield a compromise later in the year.

So we have a national problem (admittedly worse in some states than others). We may have no acceptable solution. The politics are bothersome.

With medical liability premiums rising and some doctors leaving their practices as a result, proponents of malpractice changes say caps on jury awards are necessary.

Doctors, insurers and business groups, all of whom contribute substantially to Republicans, are lobbying heavily for the bill.

But opponents, mainly trial lawyers and consumer groups and the Democrats they support, say the bill, modeled after a California law, would deprive malpractice victims of their day in court without solving the insurance problem.

They say the $250,000 cap is too restrictive.

“We have tried during the first six months of the year to see if we can’t build a bipartisan consensus on this, and thus far have been unsuccessful,” said a spokesman for Senator Frist, Bob Stevenson. He added, “We view this as a long march, and this is the beginning of it.”

That march may well extend until the next election, in 2004. Some Democrats ? who complained that Dr. Frist is circumventing Senate procedure by bringing the measure up for a vote before it has been considered in committee ? said he is using the vote to generate a political issue for Republicans.

Republicans made it clear that they intended to use the vote against Democrats.

“Women are having trouble finding obstetricians to be able to deliver their babies,” said Senator John Ensign, Republican of Nevada, the chief sponsor of the measure.

“In states like Nevada, doctors are leaving in droves, and that kind of scenario is repeating itself over and over around the country,” Mr. Ensign said. “As voters become aware of it, I think you’re going to see the change of minds of senators who may now be against it. We bring it up for a vote now, and it may cost them in the next election.“

NY Times on prescription drug benefits

Relief From High Drug Costs

Senate committees will take up two bills this week that could help many Americans cope with the ever-rising cost of prescription drugs. With both parties looking toward the 2004 elections, the chances are improving for useful drug legislation to be approved by Congress and signed into law by President Bush.

The most important bill, to be considered by the Senate Finance Committee, would add a prescription drug benefit to the Medicare program for elderly and disabled Americans. This is a badly needed benefit that would drag Medicare into the modern age by including drug coverage alongside the traditional hospital and medical coverage.

Some patients need a prescription drug benefit. We should take into consideration ability to pay. If not, any plan could have major financial implications on Medicare.

Prather on prescription drug benefit

Congress continues to work on providing a prescription drug benefit. We all want such a benefit, but many worry that we cannot really afford that benefit. As usual Robert Prather has weighed in – There Ain’t No Such Thing As A Free Lunch (TANSTAAFL). Now I know that TANSTAAFL comes from a science fiction book, written by Robert Heinlein. It should become a widely used phrase.

Robert Samuelson, who is always refreshingly honest, says flatly that a prescription drug benefit for Medicare is a bad idea. I agree. My solution, as I’ve said numerous times, is to provide Medical Savings Accounts (MSAs) coupled with catastrophic care insurance for hospitalization. The MSAs could be used to buy drugs, but would also cover doctor’s visits, blood tests and the like. Insurance would only be used for emergencies, as it was originally intended.

Social Security has an unfunded liability of $8.7 trillion in 2002 dollars and Medicare has an unfunded liability of $5.9 trillion in 1999 dollars. Together they represent more than our annual GDP. Nothing less than radical reform of both systems is required or the burden placed on future workers will be crippling. Adding a prescription drug benefit will only add to an already tremendous problem.

The Republicans are being dishonest but are trying to add a cheap version of the drug benefit. The Democrats are being even more dishonest in saying they can provide universal care and the drug benefit and pay for it by simply repealing the Bush tax cuts. As Samuelson points out, the real cost of the drug benefit doesn’t kick in until 2011 and the projections currently being used only account for two of those years. Nor does it include the inevitable increase in demand for prescription drugs because they will now be “free”.

Read his full entry and especially the comments. Prather speaks logically – this means he is unelectable – but I admire his reasoning.

Worldwide AIDS funding approved

We have followed this story closely for several months. This link summarizes the final bill – $15 Billion AIDS Plan Wins Final Approval in Congress

The politics of a Medicare drug benefit

Congress and the President are now focusing on a Medicare drug benefit. We should all view this debate cautiously. Pharmaceutical costs have a major impact on the sick. Without a drug benefit, only the wealthy can afford our many medication advances. We all agree that we would like to provide a benefit to all Medicare beneficiaries, however, we also must consider the fiscal viability of any such plan. Herein lies the debate, which the NY Times outlines well – Bush Drug Proposal in Medicare Plan Faces a Stiff Battle.

As Congress begins drafting Medicare legislation, one of the most contentious and politically explosive issues is whether the same drug benefits should be available to all.

The Bush administration and many of its allies on Capitol Hill say they want to use prescription drug benefits as an incentive to encourage older Americans to enroll in private health plans. People who stay with the traditional, government-run Medicare program would receive only modest drug benefits, while those who join private plans would be rewarded with much more extensive coverage.

White House officials and Republicans in Congress say the private plans would be more efficient than Medicare’s lumbering bureaucracy. But the idea of using drug benefits to entice elderly people into those plans is in trouble on Capitol Hill.

Democrats are almost universally opposed to the effort, which they deride as a move to privatize Medicare. More ominous for the administration is the opposition of many Republicans, including several moderates who bucked the White House on tax cuts and several powerful lawmakers from rural states.

The debate is gaining urgency as Congress begins an intensive six-week drive to pass Medicare legislation, potentially one of the most significant domestic policy bills of the legislative session and one that is already behind schedule because of the struggle over tax cuts.

I personally am conflicted over this issue. Sorting out the pros and cons is, at least for me, dizzying. I do understand both sides of this issue, and can make a strong case either way. I could also attack each position.

The cost of prescription benefits will become staggering. How we pay for that benefit will, unfortunately, impact how we pay for the rest of health care. We should follow this debate and watch how the politics unfold. The process makes me uneasy.

More on Universal Health Care

Found this link thanks to Jane Galt – Asymmetrical Information. Premium Blend: Why is it so difficult to provide universal health care?

…the core economic issue: It’s the rising cost of health care that has left some 41 million Americans without health insurance today. For the last 30 years, health-care costs have been rising 6 percent to 8 percent a year—more than double the inflation rate in the rest of the economy—because demand keeps outstripping supply. Moreover, the forces behind this exploding demand cannot easily be changed or affected. As people’s real income rises, they expect more medical care; our society is aging, so people need more care; and with new technologies treating formerly intractable conditions, people want more care.

In practice, almost everyone, insured or not, has access to health care, especially in emergencies. Insurance affects how much people actually use health services: The access of the uninsured involves inconveniences and costs that encourage them to underconsume medical services, sometimes with grim results. By contrast, people with insurance often have such broad access that many overconsume those services. These consumption patterns drive the price increases that ultimately shrink insurance coverage. Still, it’s hard to blame Gephardt or Dean for skipping past the cost issues, since every effort in the last 30 years to stem those costs—creating Medicare and Medicaid, wage and price controls, government threats of strict cost containment regulation, and the rapid spread of managed care—has failed. Anyway, who gets elected president by telling people that their health-care costs will soar so long as everybody has access to the most expensive forms of care?

The problem lies not in people’s natural desire for the best (and most expensive) care, but in the way our health-care market operates—especially the weakness of the market forces that normally slow high inflation. That makes health care a prime example of what economists call “path dependency,” where pivotal events from long ago shape a sector’s development more than normal competitive forces. Health care’s path began when employers in World War II, desperate to attract workers without breaching wage controls, first offered health insurance as an untaxed fringe benefit. This approach took strong root, because tax law requires that firms providing any tax-free form of compensation have to offer it to all their employees.

Over time, these beginnings brought most people into an insurance system that insulated them from the full cost of each treatment; they also left government as the insurer for everyone outside the work force, notably retirees and the poor. All insurance markets are subject to “moral hazard,” where the small personal cost of using the insurance—a co-payment in this case—encourages people to overuse it for minor complaints. The hazard is intensified in the case of health care, because people don’t pay for the insurance directly. To be sure, working people ultimately pay for their coverage in lower and slower-rising wages, but the cost of premiums is still subsidized by its tax-free treatment; and since employers write the checks for us, we don’t even feel the pinch directly when premiums go up. (Imagine how much less coverage many would accept if we all had to write annual premium checks for $4,000 or $5,000.) These hazards are even greater in public-sector health care, where the retirees and poor people consuming most of the services don’t bear most of the taxes financing them.

Individual costs are rising, but other forces continue to undercut greater price discipline. In most markets, for example, this discipline also depends on people having the information required to judge the value of goods or services before they buy them. In health-care markets, how many people have the information to say no to a more expensive test for diabetes or a treatment for a heart murmur? The norms of the medical profession are supposed to reduce this “agency” problem by aligning a doctor’s incentives with a patient’s medical interests (especially when the prospect of a malpractice suit reinforces these incentives). But there’s no mechanism to align the financial interests of doctors and their patients. So doctors can deliver sound health services in ways that maximize their billings.

When prices rise unusually fast in other markets, people can usually find and substitute cheaper products: Beef prices rise and people eat more chicken, or a real-estate bubble drives up housing prices and people downsize their residential ambitions. That doesn’t work nearly as well in health care, when patients are told that the alternative to a costly test or procedure is poor health or even premature death.

Finally, health-care inflation suffers from a classic “free rider” problem. Everyone has a common interest in moderating demand if it will ensure continuing coverage. But no one has an incentive to take the step alone, so no one does.

I hope you read those paragraphs carefully. Shapiro has summarized the dilemma of health care costs beautifully!!

He offers a modest solution, but admits that it is unlikely to work. As long as we have no connection between health care costs and personal expenditures, we likely will have no major health care reform.

Economists cannot tell us how much health care we need . Rather, as a society we determine how much health care we want . Unfortunately, our desires have no relation to what we would spend. The current system has no balances. Universal health care would not improve that problem, it would only shift the locus of control. One need only look to Canada and Great Britain (amongst many) to understand the types of health care cost decisions made in a single payor system.

Our health care insurance system is broken. Perhaps we could look at ways to improve that system, and in some way link behaviors with costs (e.g., smokers and the obese would pay higher insurance) and expenditures with graduated co-pays. Only when each individual starts to understand costs will market forces apply. Without the power of market forces, I suspect that we will be continuing this debate for many years.

Read Jane Galt on Dean’s health care proposals

Like Jane Galt, I am working through my thoughts on the Democratic health care proposals. In the meantime, read these two posts from her site – HillaryCare, Part II. In this post, she challenges readers

But here’s the thing: I’m unaware of any situation in which sick children go without seeing a doctor simply because their parents can’t afford it. Poor people have Medicare. Less poor, uninsured people have free clinics, out-of-pocket payments, or the emergency room. The only situation in which I can see this occurring — that a child goes without a doctor simply for lack of health insurance, rather than because of other parental dysfunction — is one in which a lower-middle-class family cares more about their credit rating than their child. In other words, it seems vanishingly unlikely.

But perhaps I’m wrong. Can anyone produce evidence — not anecdotal, “my cousin says. . . “, but real data consisting either of peer-reviewed studies not funded by single-payer advocates, or of personal experience in which you, or a member of your immediate family, did not take a sick child in need of medical attention to the doctor because of the expense? Children with the flu, or other non-fatal maladies for which the only treatment is rest and liquids, do not count. Perhaps in some theoretical medical textbook world, they should see a doctor to ensure that it’s nothing serious — but my mother didn’t take us to the doctor for those things, and we had perfectly good health insurance. The pain-in-the-ass factor is too difficult to separate from the expense factor in mild illnesses, so please — only serious cases.

So Jane instead gets an email example which proves her point. Wow. I just got this amazing response to my post on Dean’s health care rhetoric: The response is heartwrenching and finishes with this quote

I don’t know if anything I’ve written above might be of use to you in your coming “pungent words”. I have to admit, writing this was at least 20% therapy for me (I’ve wanted to say these things for some time now – your post just opened the door). But I have a very compelling reason for opposing anything resembling HillaryCare.

I’ve been through the worst case scenario most HillaryCare advocates like to use as a rhetorical bludgeoning tool – and it convinced me just how wrong they are.

Sowell on universal health care

I have been planning to rant about universal health care. As I have been thinking through this issue, I am attracted to this piece by Thomas Sowell. I will quote liberally, because the link is not permanent! “Universal health care”

If there was one defining moment in the debates among an already crowded field of Democrats seeking their party’s presidential nomination in 2004, it may well have been when Congressman Dennis Kucinich, pushing for government-provided health care, spoke with obvious disgust of the “profits” of the insurance companies and provoked a burst of spontaneous applause from like-minded members of the audience.

Insurance companies, like every other kind of institution, have to earn money in order to keep functioning. So does every individual who was not born rich. But some people react to the word “profit” with automatic responses, like Pavlov’s dog.

While I often have problems with the insurance companies, I do not resent them making a profit. Rather I resent the tactics they use to make those profits.

But, just as there are still pockets of resistance in Iraq and Afghanistan, so there are still holdouts like Congressman Kucinich and like-minded Democrats. Socialism has been discredited as an explicitly avowed belief but it still lives on in a thousand disguises, of which “universal health care” is just one.

Like so many pretty words used in politics, “universal health care” is seldom examined in terms of what its actual track record has been in the countries where it has been tried.

Probably the first country to have universal health care provided by the government was the Soviet Union. After decades of socialized medicine, what was the end result? In its last years, the Soviet Union was one of the few countries in the world with a declining life span and a rising rate of infant mortality.

But that terrible word “profit” had been banished and apparently that is what matters to the true believers.

Not all countries that tried socialized medicine went as far as the Soviet Union. But there has been a whole pattern of problems common to government-controlled medical care systems, whether in China, Britain, Canada or elsewhere. And none of the anti-profit zealots want to talk about any of those problems.

None of those who wants us to move in the direction of Canada on health care ever faces the question: Why do so many Canadians come to the United States for medical treatment and so few Americans go to Canada?

Could it be that we should look at what actually works, rather than what sounds good? Nor should we be overly impressed by words that sound bad, like “uninsured Americans.” The bottom line is medical care, not insurance. People without insurance are treated at hospitals all across America every day.

Before we even consider throwing away what works in favor of something that has failed repeatedly, we need to stop reacting to words and start looking at facts. Socialism by any other name is still socialism — whether it is advocated by shrill zealots like Kucinich or by other Democrats whose words are smoother.

While I will take issue with some of Sowell’s arguments, he generally does understand. Our current system is flawed – a problem which I plan to address later this week. Meanwhile, please share your thoughts on this piece.

Good news in DC

House Adopts Global Plan of $15 Billion Against AIDS

The House adopted a $15 billion initiative to combat AIDS worldwide today. The vote was taken after conservatives won a requirement that at least one-third of the money promote sexual abstinence before marriage.

The concession helped solidify support for a measure for AIDS treatment, research and education that is a priority of the Bush administration, and it resulted in a strong bipartisan vote in support of a social measure in the usually polarized House. The vote was 375 to 41.

…

Advocates welcomed the vote and said the abstinence language would not pose a serious problem. One advocate said the important development was that Republicans were voting for a measure to endorse condom distribution while Democrats backed abstinence programs.

“That is a pretty good start,” he said.

Indeed it is!!!

On politics and health care

Now it become official. We (the medical blogger community) have been discussing the health care crisis for many months. Today the NY Times declares it so! Health Care Limps Up Political Ladder

They (and the Democrats) rarely look at the true underpinnings of this crisis. We need solutions which diagnose the disease, not those which try to treat the symptoms.

The stupid war – the war on drugs

Consistent readers understand that I approach most issues from a libertarian viewpoint. You are entitled to great freedom, but the freedom of your fist ends at my nose. I argue, often without much success, that our war on drugs creates many more problems than it possibly prevents. While I understand the ravages of drugs on our youth and also many adults, the costs of the drug war (not monetary costs, but criminalization of large sectors of society, murders, robbery, etc.) far exceed the costs that would associate with decriminalization. As always, one must choose which costs are worse, costs of omission or costs of commission. We know the costs of the drug war.

This commentary does an elegant job of summarizing the problem. The war on drugs

Prominent drug legalizers or decriminalizers read like a who’s who of conservatives: William F. Buckley Jr., Milton Friedman, New Mexico Governor Gary Johnson, Ronald Reagan’s Secretary of State George Shultz.

Mr. Shultz, now at the Hoover Institution with Mr. Friedman, is but a recent convert. In 1984, he sang a different tune, declaring: “Drug abuse is not only a top priority for this Administration’s domestic policy, it is a top priority in our foreign policy as well.”

The background for the Shultz conversion is well-demonstrated in “Bad Neighbor Policy” by Cato Vice President for Defense and Foreign Policy Studies Ted Galen Carpenter, who dwells here on the more than 30 years since President Nixon declared a War on Drugs. Mr. Carpenter tweaks the title of his timely and instructive book in a play on Franklin D. Roosevelt’s Good Neighbor Policy for Latin America in the 1930s, as he documents multiple U.S. sins south of the border and comments on our stepped-up war on drugs:

“U.S. officials have bribed, cajoled, and coerced Latin American governments to try to stem the outflow of illegal drugs. The result has been a rising tide of corruption and violence in those countries and a growing dissatisfaction on the part of affected populations with their own governments ? and with the United States. Washington’s hemispheric war on drugs is the epitome of Bad Neighbor Policy.”

We need rationale in this discussion, but I fear we will only get emotion. Some drugs are deadly, but the drug trade itself is – I believe – more deadly. We need enlightenment here. I doubt that we will get that enlightenment.

Medicare drug benefit – new ideas

Medicare Drug Benefit Plan Is Proposed by 2 Democrats. I have previously ranted that we really cannot afford to provide a complete drug benefit for all Medicare aged patients. Finally, some Democrats agree.

In a break with party leaders, centrist Democrats proposed today that Medicare provide drug benefits immediately to people who have low incomes or high prescription drug expenses.

Members of both parties said Congress could eventually embrace such a plan if lawmakers could not agree on more ambitious proposals to pay drug costs for all Medicare beneficiaries, regardless of income.

The new proposal was offered by Representatives Cal Dooley of California and Rahm Emanuel of Illinois, with support from 16 other House members who call themselves New Democrats.

“Our proposal is fiscally and politically realistic,” said Mr. Dooley, a House member for 12 years. It would, he said, provide drug benefits to people with the greatest financial needs.

Mr. Emanuel, a freshman who worked in the Clinton White House, said the proposal provided “a solid foundation on which Congress can build.”

Howard J. Bedlin, vice president of the National Council on the Aging, a research and advocacy group, said, “This is not the ultimate solution, but it would be a good start, a potential compromise, that could attract bipartisan support if we find there’s not enough money to provide more comprehensive drug benefits.”

Under the proposal, Medicare would pay 80 percent of the cost of each prescription after a beneficiary had incurred $4,000 of drug costs in a year.

The $4,000 deductible would not apply to elderly people with incomes less than twice the poverty level. For the poorest among these, the federal government would pay at least 80 percent of their drug costs, and the federal share would decline as a person’s income rose toward 200 percent of poverty. The poverty level for a couple is $12,120 this year.

This proposal has the advantage of making sense. We should strive to help those who clearly need governmental help. A $4,000 deductible makes more sense for those with adequate incomes.

Moynihan

This blog will remain 99% medicine. However, I must comment on Daniel Patrick Moynihan.

I generally vote Republican. My political philosophy is best described as Libertarian domestically and neo-conservative internationally. (see Robert Prather to better understand this – Neocons Vs. Paleocons.

Regardless of ones political inclinations, Daniel Patrick Moynihan should represent the ideal in politics. He based his stands on principle and intelligence. Even when one disagreed with him, one had to reconsider ones own position, because he was so damn smart. Read this outstanding tribute from George Will – A Beautiful Mind. Oh, but that we could have the Congress full of his like!

Medicare relief – for this year

Now official, we will receive a slight increase for each patient visit in 2003. Physicians win Medicare payment relief: With an increase secured for 2003, the AMA will focus on preventing a cut next year.

Physician groups already have begun a push to modify the way payment updates are calculated each year. Sara Walker, MD, president of the American College of Physicians–American Society of Internal Medicine, said additional changes in Medicare policy would be needed for payments to keep pace with increases in practice expenses.

“We look forward to working with the Centers for Medicare & Medicaid Services on implementing the beneficial changes approved by Congress, as well as other changes in Medicare payment policies that may be required,” Dr. Walker said. “The goal must be to assure that Medicare patients have continued access to physician services by guaranteeing that Medicare payments will keep pace with the rising costs of delivering care.”

Physician groups have urged CMS to exclude the cost of outpatient prescription drugs and clinical laboratory tests covered by Medicare from its calculation of the spending targets for physician services. Physicians argue that they have no control over the price of those drugs and should not be penalized for the rampant inflation in drug costs in recent years.

So this story will continue, but today’s chapter has a decent ending.

Political Health News

Bush Seeks Funds for Wider Effort to Curb Chronic Disease . I like the initiative to try and reduce diabetes, obesity and asthma. These are becoming public health problems. We need to find creative solutions to encourage healthier lifestyles. Money will lead to innovative program trials.

This article also addresses smallpox vaccination side effects – and how we cover those. Primum non nocere!

A physician as majority leader

It appears that Trent Lott is stepping down and Dr. Frist will become majority leader – Lott Steps Down as Senate Republican Leader . I believe this is a very important move for medicine. Frist has championed many important causes – Medicare reform, malpractice reform, etc. Being majority leader, he will more likely have the Senate address these important issues sooner rather than later. I will try to watch his interviews and read commentaries which relate to this hope.

Republican health care agenda

Healthcare getting greater attention .

“It is clear that healthcare will be a real priority for this administration,” Grace-Marie Turner, president of the Galen Institute, told United Press International. “It is genuinely refreshing because Republicans have always been weak on these issues.”

Since the election, Karl Rove, President George W. Bush’s chief political adviser, and other top officials have been making the rounds of think tanks and health care advocacy groups in an attempt to garner support for a far-reaching reform agenda. At the same time, congressional leaders are reportedly gearing up for policy efforts that may be at odds with the White House plans.

…

Rove, for example, has been talking up the administration’s health policy agenda, stressing the importance of making progress on the issue in the new Congress.

According to those who have attended meetings with Rove, he has outlined an agenda that focuses on medical malpractice reform, Medicare reform with the possible addition of a prescription drug benefit, and on government help for the uninsured.

According to one administration source, Rove is prioritizing policies that can help gain political capitol for Republicans in the 2004 election, but that also do not have large budgetary needs. Medical malpractice reform, for instance, is said to be a top priority of the administration precisely because it will cost little to implement.

Those who follow the issue also see the fact that the nation’s trial lawyers are also major supporters of the Democratic party as a significant driving force behind Republican support for limiting damages in medical malpractice cases.

But Tom Miller, director of health policy studies at the libertarian Cato Institute, said that prospects for such a bill are limited, given the small margin of power the Republicans now hold in the Senate, which falls short of the 60 votes needed to kill a Democratic filibuster of such a measure.

Unfortunately, we must all follow the politics carefully. What happens in Congress affects our practices and our ability to provide excellent care to patients. Unfortunately, politicians are not really worried about patient care. As I have written often, the Democrats position on malpractice reform is not understandable. Nor is the Republican position on the pharmaceutical industry. Hopefully, we can get some progress this year. (I remain the eternal optimist).

Physician fees

Senate leaves Medicare pay fix undone: Congress adjourns before addressing the problems with the physician reimbursement rate. Now the new rates will be published. Congress has 60 days to change the published rate, so all is not yet lost. Secretary Thompson of HHS says this is a high priority.

I still cannot understand why the Senate would not address this issue previously. Since the House passed a bill fixing the rate problem twice, I must hope that the new Republican majority Senate will address this successfully. We must follow this issue carefully. Organized medicine has united in working for this issue.

The War on Drugs explained

I do not really understand the war on drugs (the illegal ones). Our government spends billions of dollars and what do we get? We support semi-organized crime, gang wars, and make millions of Americans criminals. We allow drug prices to increase (law of supply and demand), and at least for the more addicting drugs, either bankrupt users, or see them commit various crimes (theft, armed robbery, embezzlement). For very interesting reasons, the ‘war on drugs’ is now focusing on marijuana. I recommend this well conceived op-ed piece from the NY Times – Reefer Madness

The drug liberalizers — an alliance of legal reformers, liberals, libertarians and potheads — dwell on marijuana in part because a lot of the energy and money in their campaign comes from people who like to smoke pot and want the government off their backs. Also, marijuana has provided them with their most marketable wedge issue, the use of pot to relieve the suffering of AIDS and cancer patients. Never mind that the medical benefits of smoking marijuana are still mostly unproven (in part because the F.D.A. almost never approves the research and the pharmaceuticals industry sees no money in it). The issue may be peripheral, but it appeals to our compassion, especially when the administration plays the heartless heavy by sending SWAT teams to arrest people in wheelchairs. Thus a movement that started, at least in the minds of reform sponsors like the billionaire George Soros, as an effort to reduce the ravages of both drugs and the war on drugs, has become mostly about pot smoking.

The more interesting question is why the White House is so obsessed with marijuana. The memorable achievements of Mr. Walters’s brief tenure have been things like cutting off student loans for kids with pot convictions, threatening doctors who recommend pot to cancer patients and introducing TV commercials that have the tone and credibility of wartime propaganda. One commercial tells pot smokers that they are subsidizing terrorists. Another shows a stoned teenager discovering a handgun in Dad’s desk drawer and dreamily shooting a friend. (You’ll find it at www.mediacampaign.org. Watch it with the sound off and you’d swear it was an ad for gun control.)

Drug czars used to draw a distinction between casual-use drugs like marijuana and the hard drugs whose craving breeds crime and community desolation. But this is not your father’s drug czar. Mr. Walters insists marijuana is inseparable from heroin or cocaine. He offers two arguments, both of which sound as if they came from the same people who manufacture the Bush administration’s flimsy economic logic.

One is that marijuana is a “gateway” to hard-drug use. Actually Mr. Walters, who is a political scientist but likes to sound like an epidemiologist, prefers to say that pot use is an “increased risk factor” for other drugs. The point in our conversation when my nonsense-alarm went off was when he likened the relationship between pot and hard drugs to that between cholesterol and heart disease. In fact, the claim that marijuana leads to the use of other drugs appears to be unfounded. On the contrary, an interesting new study by Andrew Morral of RAND, out in the December issue of the British journal Addiction, shows that the correlation between pot and hard drugs can be fully explained by the fact that some people, by virtue of genetics or circumstances, have a predisposition to use drugs.

We need some common sense here – but I do not expect to see any.

Health Care is Crisis

Problem of Lost Health Benefits Is Reaching Into the Middle Class

According to recently released Census Bureau figures, 1.4 million Americans lost their health insurance last year, an increase largely attributed to the economic slowdown and resulting rise in unemployment. The largest group of the newly uninsured — some 800,000 people — had incomes in excess of $75,000. They either lost their jobs, or were priced out of the health care market by rapidly rising insurance premiums, or, like Ms. MacPherson, both.

While it is true that the number of uninsured people rises when unemployment goes up, it is also true that the rolls of the uninsured can expand even when joblessness is going down, as it did through most of the 1990’s.

So how do we improve the system. As one would expect we have differing opinions from the Democrats and the Republicans.

On the other hand, proposals to aid the uninsured could easily touch off a partisan brawl, in which lawmakers fight over the merits of government programs versus the private market.

President Bush has already proposed tax credits and is expected to offer more proposals to help the uninsured as part of his budget early next year.

In his first two budgets, Mr. Bush earmarked a large amount of money for health insurance tax credits: $89 billion over 10 years, for people who are not covered by an employer’s plan and not eligible for public programs. The proposal languished in Congress, but Mr. Bush will have a greater incentive to push for action this year.

“The president wants to develop a record on health care to neutralize this issue going into the 2004 elections,” Mr. Pollack said.

The issue is of particular concern to small-business owners, who say they would like to offer their employees health insurance but cannot keep up with the fast-rising premiums. They are a large and influential lobby and an important base for the Republican Party.

Regardless of political action, we have a huge problem. The care we expect costs too much money. The tests are expensive; the hospital care is expensive; and medication costs … well no sense in flogging a dead horse.

Medicare drug plan

The Washington Post speculates on the probability of a Medicare drug plan from the new Congress – Medicare drug plan likely to move

Republican health agenda

Bush and G.O.P. to Push for Medicare Drug Benefit

Republicans say they are planning to use their new control of Congress to provide prescription drug benefits to the elderly, while offering tax credits to the uninsured and imposing new limits on damages in medical malpractice cases.

President Bush, Speaker J. Dennis Hastert and Trent Lott, the Senate Republican leader, all said health care legislation would have a high priority in the 108th Congress, which convenes in January. Republican candidates for Congress promised to add drug benefits to Medicare, Mr. Bush made a similar promise two years ago and Democrats have vowed to hold Republicans accountable in the 2004 elections.

…

The biggest source of disagreement is how to balance the roles of government and private industry — a question that goes to the heart of the two parties’ philosophical differences. Democrats favor a larger role for the government, while President Bush and Congressional Republicans would rely heavily on competing private health plans and pharmaceutical benefit managers, like Express Scripts and Medco Health Solutions, a unit of Merck & Company.

Republicans said the starting point for any measure would be a “tripartisan bill” drafted over the last two years by Senators Charles E. Grassley of Iowa, Olympia J. Snowe of Maine and Orrin G. Hatch of Utah, all Republicans; James E. Jeffords, independent of Vermont; and John B. Breaux, Democrat of Louisiana.

Under the proposal, the government would pay subsidies to private insurers to get them to offer drug coverage with a monthly premium of about $24 and an annual deductible of $250. The standard Medicare insurance policy would cover 50 percent of drug costs up to $3,450 a year; after beneficiaries spent $3,700 of their own money, the government would cover 90 percent of drug costs.

So that is their plan for a drug benefit. They argue that we just cannot afford a ‘no holds barred’ benefit, this is expensive enough. This plan would certainly help many and may be practical.

The other items on the Republicans’ health agenda are intended to address the rising cost of care and coverage. For two years, Mr. Bush has asked Congress to authorize tax credits for the cost of health insurance bought by people who are not covered by an employer’s plan and not eligible for public programs. The president’s commitment is reflected in the large amount of money he would devote to this proposal: $89 billion over 10 years.

Many Democrats have balked at tax credits for health insurance. They say the government could cover more people at lower cost by expanding programs like Medicaid, for low-income families. But recently, some have said they are willing to consider tax credits, if the government sets standards for the insurance bought with such assistance.

This plan seems quite fair. It would greatly reduce the number of uninsured if I understand the plan correctly.

Republicans in both houses said they would also push for legislation to cap damage awards in medical malpractice lawsuits. The House passed such a bill in September, 217 to 203, but Senate Democrats have shown no desire to act on it.

President Bush strongly supports the House bill, saying it would slow the rise of malpractice insurance costs for doctors and hospitals.

The House bill would cap damages for “pain and suffering” at $250,000 and limit punitive damages to $250,000 or twice the amount of economic damages, whichever is greater. Plaintiffs’ lawyers oppose the bill, saying it would unfairly limit compensation for the loss of a child or a spouse, or a limb or sight.

These provisions work well in California. We have discussed it often in the past. I hope that we get this relief in the very near future.

Oregon says no to Measure 23

In an apparently overwhelming vote, Oregon has defeated measure 23 by almost 4-1. Sanity reigns in Oregon. The voters understood the trade-off between a great ideal and the fiscal insanity that it would bring.

Do we really want a National Health System?

We must always look to England. They experiment for us. Read this diatribe Bedside stories: When Alan Milburn starts being rude about doctors on the telly, it’s hard to see how the NHS is going to survive

“The NHS is over; we’re all going to be rich. They have really pissed on their chips this time.” My registrar is in a particularly bad mood: he has just seen the health minister on TV, accusing doctors of being greedy for not accepting the new consultants’ contract. I look around the drab on-call room. It is not easy doing a day’s work, working the whole night and then working the whole of the next day. Working 33 hours in a row makes you feel shit: it makes you split up with your girlfriend, it loses you your mates, it stops you going out and it makes you crap at your job. It’s illegal, except that the government got some special dispensation to exempt us from European employment law. And it’s cruel. You just need more doctors. So train more doctors.

So why have we always done it? Not for the money: my basic salary is £23,000 and I’ll send you a photocopy of my payslip to prove it. We do it because we have a collective Mother Teresa complex and, to be honest, because it feels good to work insanely hard, but to know that you are doing a good job for society, and that you are appreciated for it.

But when people start to be rude about us on telly, when we are all made to look like the minority who practise badly, when patients are over-demanding and rude to us in casualty and in GP surgeries, then that’s it. I’m telling you, with the mood every doctor in the country is in, this is the end of the NHS, the greatest state healthcare system in the world, which we were all truly proud to work in.

And get this: with the attacks on doctors in the media, and patients’ temper tantrums in casualty at three in the morning, the NHS will be killed forever, not by some restructuring or government policy, but by sheer, simple, old-fashioned rudeness. It’s not ironic, it’s stupid and sad.

So this is what happened with the new contract. We are not greedy. We did not go to the government demanding more money. They came to us and told us we had to stop doing private practice, and be available to work until 10pm and over the whole weekend for the entirety of our working lives, until we retire. And we told them to forget it. You would too.

Physicians in England are about to revolt! This could happen to us. It just might happen in Oregon.

du Pont weighs in on Measure 23

Beaver State Bolshevism: Will Oregon voters approve a Leninist approach to health care?

But none of this seems to have registered on Democrats, Greens and the NAACP in Oregon, where they have put on the ballot in next week’s election a Leninist plan for health care under which the government and only the government would provide, deliver, regulate and finance medical services to Oregonians. The services provided would include comprehensive health care and everything related thereto– from brain surgery and prescription drugs to marriage counseling and massages, from inpatient hospital care to long-term care for the elderly. And they would all be absolutely free to individuals and families–no deductibles, no copayments, no premiums.

The cost to taxpayers would be enormous. The ballot initiative would authorize $9 billion in new expenditures on top of the $16 billion Oregon currently spends on all government services, a 56% increase in the cost of government. The American Association of Health Plans estimates that about $15 billion in new taxes will be required to finance the program, an average of $5,000 per resident.

To pay for these “free” services, Oregon would increase its top income-tax rate–which applies to married couples earning as little as $12,500–to as much as 17% from an already high 9%, giving Oregon by far the highest income-tax rate in the country. Payroll taxes on employers would increase to 11.5%, doubling or tripling the current rate (depending on salary levels), an enormous financial burden on businesses that would guarantee a significant drop in employment.

His rant continues with more explanation of the problems. While I believe he skillfully uses hyperbole, he does make some interesting points. I wish the solution to our health care crisis was simple; I fear that it is anything but simple.

Medicare payment crisis

Lower Medicare Payouts Concern Bush Officials

Bush administration officials say they have become deeply concerned that a cut in Medicare payments to doctors, to be announced next week, will prompt many doctors to limit their participation in the program, reducing access to health care for the elderly.

Medicare payments to doctors were cut 5.4 percent in January, and Medicare officials said that next week they expected to announce a further cut of 4.4 percent, effective on Jan. 1.

Asked to describe the likely effects, Thomas A. Scully, administrator of the Medicare program, said: “You’ll have mad doctors. There will be access problems, and seniors will feel it.”

The cuts result from a formula specified in the Medicare law. The Bush administration says it has no discretion to halt the cuts, a contention disputed by doctors and by some influential lawmakers.

In March, doctors in a dozen states said, in interviews with The New York Times, that they were refusing to take new Medicare patients because Medicare was paying them too little to cover their costs. A second cut will accelerate the trend, doctors said this week.

Many private insurers link their payments to the Medicare fee schedule, compounding the effects of any cut in Medicare reimbursement.

Tommy G. Thompson, the secretary of health and human services, said this week that he and Mr. Scully were “very concerned” about the impending cut.

Administration officials said President Bush’s chief of staff, Andrew H. Card Jr., and his senior political adviser, Karl Rove, had taken an interest in the cut, in part because the administration did not want to alienate doctors or the elderly two weeks before Election Day. Democratic candidates are always hunting for evidence to back their argument that Republicans want to cut Medicare.

This long article goes on to outline the reasons why this has occurred and why the Congress did not fix it this year. Physicians are tired of excuses. Who will care for the patients? We already lose money taking care of Medicare patients.

Those in favor of a single payor health system need only look at this experience to understand why many physicians fear such systems. Congress and the Administration both know that these rates need repair. Nonetheless our political process is unable to develop a solution.

More on Oregon

The print edition of the Wall Street Journal had a good editorial on the Oregon Measure 23 vote. As one would expect, they argue against the Measure. So does Sydney Smith. She has an excellent essay – The Pacific Northworst in Tech Central Station. She follows that up today in her blog – Point/Counterpoint. I recommend reading both links if you are interested in this issue. Sometimes Medpundit and I agree, sometimes we disagree. On this issue we are walking side by side.

Washington Post on Oregon Measure

Oregon Ponders Universal Care . My post on this issue last week has engendered excellent and impassioned comments shows how important this issue is.

The measure could pass: The most recent polling, by the Portland Tribune, found that 36 percent approved of the plan, 39 percent opposed it, and 25 percent were undecided, with a margin of error of 4 points. The initiative was winning among Democrats and women, and trailing with men, independents and Republicans. An earlier poll by the Oregonian newspaper found 49 percent against the measure and 40 percent for it, with the remainder undecided.

The next week will be crucial, because Oregonians vote by mail (their ballots must be received by Nov. 5). The organized groups opposing the health care experiment have yet to run television spots, though they have about $400,000 on hand and are expected to start their ads any day.

If the initiative actually passes, said Rachel DeGolia, a director of Cleveland-based Universal Health Care Action Network, “it will really wake people up.”

DeGolia said efforts are now targeted at the state level as universal health care advocates have been frustrated in their bids to revive debate and congressional action in Washington after the Clinton administration’s failed attempt to retool health care finance in 1993-94.

If this passes it will either pave the way for the country or become a measure disaster for Oregon. I hope that it would work. I agree with the ideal, but the implementation worries me.

On Oregon’s measure 23

I wrote earlier this week on the Oregon measure for universal health coverage. I am quoting two editorials from the Oregonian rather than providing links because those links appear unstable.

Should we have universal health care? YES

10/07/02
BRITT McEACHERN

This fall, we Oregonians will cast what likely will be the most important vote of our lives, on Measure 23.

The Health Care for All initiative will give this state a chance to stand up and tell insurance companies that we cannot afford to pay skyrocketing premiums that cover a diminishing number of services.

We have the opportunity to tell them that it is unacceptable to have a health-care system in this country that has left more than 41 million people uninsured and 50 million more underinsured. We can tell them that it is unreasonable to have insurance executives taking home tens of millions of our health-care dollars every year while they force seniors to choose between food and medicine.

Measure 23 will make these and other problems of a failed industry a thing of the past, by using a designated part of state income taxes to finance health care for every Oregonian. At the same time, it will save most people money by eliminating deductibles, premiums and co-payments.

Opponents of Measure 23 love to scare you with claims that this plan has no cost controls and will be run by bureaucrats. These claims are baseless. Insurance corporations are expected to funnel millions of dollars into this campaign to spread their propaganda and dismiss the simple facts of Measure 23.

The main cost control that insurance companies use is denying care to sick people. Instead, Measure 23 will result in the use of proven cost controls, ones that are in place in other parts of the country. Bulk purchasing of prescription drugs and medical equipment, a focus on preventative care and reducing the crippling administrative costs of the current system are just a few approaches Measure 23 takes to lower health care costs.

These cost controls will provide a great benefit to the organizations that need them most, public schools. Writers of Measure 23 sent this plan to school districts around the state and found that schools would save millions. Had this plan been in effect in 2000, North Clackamas schools would have saved more than $3.5 million; Eugene, more than $2.3 million.

Right now, 25 percent to 40 percent of every dollar we spend on health care goes to administrative costs. This broad category includes outrageous CEO salaries, paperwork and the millions spent on advertising. These costs will be capped at 5 percent after the first three years. This cost control alone will save Oregon billions of dollars every year.

In our current system, businesspeople are making out health decisions rather than our doctors. When an MBA in a cubicle denies vital medicine to a child, he or she cannot be held accountable. With Measure 23, our doctors, not the insurance executives, will determine the treatment we receive, and the people of Oregon will vote for the people to manage the system.

By offering far better care for less money than what we are spending now, Oregon will once again blaze the trail for reforms in this country.

Britt McEachern is communications director of the Oregon Yes on 23 Campaign.

And now the opposing view.

Should we have universal health care? NO

10/07/02
LISA TRUSSELL

Measure 23 would replace the current private health insurance system and create instead a costly taxpayer-funded system that would cripple Oregon’s economy.

Few argue with the goal of providing essential health care to every Oregonian. Measure 23, however, goes far beyond essential care, in providing free treatments from any type of provider.

It would roll out the welcome mat to anyone outside Oregon seeking free health care. To be a “resident” under Measure 23, people would need only indicate their intention to stay in Oregon.

State officials estimate Measure 23 would cost more than $10 billion per year, nearly doubling the entire current state general fund budget and risking further reductions in state budgets that fund the K-12 education system and other priority state programs. Proponents put the cost at more than $20 billion per year.

How will the state pay its massive new health care bill? New taxes. Measure 23 would nearly double Oregon’s top income tax rate, from 9 percent to 17 percent. Each taxpayer’s income taxes could rise as much as $25,000 per year.

Employers also would face a new tax on their payrolls of up to 11.5 percent. Such a huge tax increase would force many businesses to leave the state or close their doors. It would be a devastating blow to Oregon’s economy.

Measure 23 puts the full authority for the implementation of the new health care plan in the hands of a new 15-member Oregon Comprehensive Health Care Finance Board. Ten members of the board would be elected and five would be appointed by the governor.

The new board would have broad powers to tax, borrow and ration health care. The board also would set reimbursement rates for physicians, hospitals and other providers.

Because Measure 23 eliminates current cost-containment tools, such as co-payments and deductibles, its wide-open coverage and lack of any cost constraints would mean health care expenses would rise dramatically. In addition, Measure 23 would replace proven workers compensation cost-containment tools, as well as a treatment review process that ensures workers get appropriate care for their injuries.

Once costs overwhelm the tax system, the board would have the authority to ration health care benefit levels for all Oregonians. Canada has a similar national health plan. Canadian residents needing heart bypass surgery have to wait as long as a year to receive the surgery and many die while waiting.

Rationed care is not what Oregonians need.

Take a close look at Measure 23. It vests enormous power — too much power — in a board of state-paid bureaucrats.

If Measure 23 passes, health care costs in Oregon would soar. State budgets would be nearly tripled, and other priority state programs, such as schools, would be imperiled. The state’s economy would be ravaged by the steep, new taxes. And ultimately, Oregonians would get less care than they do today.

Lisa Trussell is chief operating officer for AOI Healthchoice.

Universal health in Oregon?

Ore. Considers Universal Health Plan

Every man, woman and child in Oregon would receive full medical insurance — no co-payments, no deductibles — under a measure on the Nov. 5 ballot that would create the first universal health care plan in the nation.

The question is whether Oregonians are willing to pay higher taxes for a plan so generous it would cover even acupuncture and massage therapy.

“What we are proposing is ambitious and audacious, but we believe the health care system now is in a crisis,” said Mark Lindgren, spokesman for the Health Care for All Oregon campaign, sponsor of Measure 23.

This vote is worth following.

The Senate and Medicare fees

Read it, but you might not like it. Senate unveils proposal for Medicare pay fix, regulatory reform: Legislation would begin to shrink the gap between rural and urban Medicare payments. Unfortunately, Senators worry much more about re-election than doing the right thing. In this case, giving fee relief without a drug benefit would appear to anger AARP. The Democrats would never want to appear to anger AARP.

The American Medical Association called on the Senate to pass Medicare payment relief before Nov. 1, when CMS will announce the final update for 2003 and physicians begin to consider whether to continue their Medicare participation agreement for the upcoming year.

“When you put the Medicare cuts together with the professional liability crisis, there is such difficulty for physicians to maintain their office overhead,” said AMA President Yank D. Coble Jr., MD. “With these huge reductions, it’s clearly creating major problems for physician offices and patients’ access to care. The House of Representatives has passed a correction, and hopefully the Senate will do the same.”

The Senate proposal’s adoption of the House-passed payment fix removes some potential conflicts between the two bodies over the legislation’s content. But the measure still faces several major hurdles. At press time, Senate leaders were leaning toward bypassing the Senate Finance Committee and bringing the measure directly to the Senate floor.

There, the bill would have to withstand challenges based on budgetary concerns, as well as the controversy surrounding addition of a Medicare outpatient prescription drug benefit — either of which could sink the entire package. Earlier this year, the Senate considered four different prescription drug benefit proposals, but none was able to garner the needed votes.

Going into the November elections, senators may be unwilling to risk the political fallout from the senior citizens’ lobby that could result from passing payment increases for doctors and others without also adding a drug benefit.

“Our members would not understand why Congress could find money again to increase provider payments above and beyond a reasonable and appropriate level, but could not help them with their prescription drug need,” the AARP said earlier this year. “Every dollar that is attributed to a givebacks package means one dollar less for a Medicare drug benefit.”

Medicare cuts without rationale

Government Proposing Cuts in Many Medicare Payments

The proposed cuts are part of a new system of paying hospitals for outpatient services. With advances in medical technology, hospitals report explosive growth in the number and kinds of procedures that can be performed in outpatient clinics, without the need for an overnight stay. Outpatient care accounts for nearly half the revenue at some hospitals.

The cuts would affect many drugs, devices and high-technology procedures, including cancer drugs and cardiac defibrillators like the one implanted in the chest of Vice President Dick Cheney to prevent an irregular heartbeat.

Medicare would also pay less for blood products given to people who receive transfusions but do not need overnight hospitalization. The Medicare payment for a unit of red blood cells — about a pint — would be cut 39 percent, to $83 next year, from $137 this year.

Federal health officials said Medicare had been overcharged for many outpatient services. But patients have joined health care providers in protesting the proposed cuts, saying that at the new prices hospitals will be unable to provide treatment to patients who need it.

“We were shocked when we saw the payment rates,” said Christopher T. Mancill, director of reimbursement policy at the American Red Cross.

The payment for inserting a battery-operated pacemaker and defibrillator would be cut 59 percent, to $12,102, from $29,360.

Doctors and patients’ advocates expressed concern that hospitals would stop providing services on which they consistently lose money. This could make it more difficult for Medicare patients to obtain life-saving drugs, devices and treatments.

The health care industry has become so dependent on Medicare that when Medicare makes its unilateral decisions, the entire industry suffers. This article points out the problem of government health support. Health care costs keep rising (and here I mean real costs, not charges which are also rising) yet the moneys available to pay for that care are shrinking. I keep pointing out our health care crisis. This will convince a few more readers. We must either increase the moneys we designate for health care, or start to ration health care. That always sounds fine for the other fellow, but totally unacceptable when I am affected. We will not easily address this problem as the solution will not be popular.

An Objectivist views ‘the right to inhale’

As the reader can tell, I am obsessed with this issue this week. I dislike passion in place of reason when it negatively affects so many lives. The Right to Inhale.

The fundamental issue involved is personal freedom from government coercion. As long as you don’t violate the rights of others, as a free individual you should have the right to do with your life—and your body—whatever you think is best, without government interference. This means, for example, that you should have the right to get drunk—as long as you pay for your beer; and the right to get drowsy—as long as you don’t drive out of control; and also the right to get stoned—as long as you don’t stone somebody else.

Many people who believe in personal freedom are nevertheless against decriminalizing drug use because they believe it would increase crime. To support their belief they point to a strong correlation between drug use and violent behavior.

While it is undeniable that such correlation exists, it does not by itself demonstrate that drug use causes crime. In fact, a Bureau of Justice Statistics (BJS) survey of prisons found that the opposite was true for half the inmates, who started their criminal careers before they had ever used a major drug. Moreover, if it were true that drug use caused crime, how would one account for the twelve million drug users who commit no crimes?

A much more likely explanation for the correlation observed is that criminals often act self-destructively. It should be no surprise that they abuse drugs and alcohol. It should also be no surprise that a great number of parents capable of neglect and violence against their children are also drug users. If they have no concern for themselves, is it any wonder that they have no concern for their children?

The fact we must face up to is that no causal connection between drug taking and violent behavior was ever identified. Certainly no such connection exists for marijuana. The theory that drugs cause crime basically misses the point that violence is an act of choice. Criminals use force against others because they think it is a valid and desirable means of gaining values. Drugs do not cause crime—criminals cause crime.

It makes no sense for government to punish all drug users because some of them are criminals. Government’s job should be to protect rights, not to trample on them.

I guess all this logic does not apply. The arguments make sense, thus I will continue to harp on this issue. We are wasting money, damaging lives and creating a criminal culture. We should not allow that.

The Libertarian Party on drug laws

Read this and think about it. It will not work, as it makes too much sense – Should We Re-Legalize Drugs? Let me quote the preamble:

Libertarians, like most Americans, demand to be safe at home and on the streets. Libertarians would like all Americans to be healthy and free of drug dependence. But drug laws don’t help, they make things worse.

The professional politicians scramble to make names for themselves as tough anti-drug warriors, while the experts agree that the “war on drugs” has been lost, and could never be won. The tragic victims of that war are your personal liberty and its companion, responsibility. It’s time to consider the re-legalization of drugs.

Medicare hope

Plan to Raise Medicare Pay for Providers

Just weeks after rejecting proposals to help the elderly with prescription drug costs, the Senate is poised to increase Medicare payments to doctors, hospitals, nursing homes and health maintenance organizations.

Consumer advocates are furious at the prospect that Congress will address the needs of health care providers without doing anything on prescription drugs, and their anger is putting political pressure on Congress to try again to pass at least a modest drug bill this year.

This is a difficult issue. If one assumes a zero sum game, where should the money go? If we do not increase Medicare payments to physicians, more patients will not be able to find physicians. Physicians are closing their practices to Medicare in droves.

So what is more important, having a doctor or having a prescription drug benefit? I do not know the answer to that question. I am certain that physicians should not lose money seeing Medicare patients. How we address a prescription benefit remains a very expensive and challenging question.

Many lawmakers said that doctors had the strongest claim to new money because their Medicare payments were cut 5.4 percent in January, and they face similar cuts in each of the next two years. Significant numbers of doctors are refusing to take new Medicare patients, saying the government pays them too little to cover the costs of caring for the elderly.

“Unfortunately,” said Representative Billy Tauzin, “the Senate has chosen to ignore this growing crisis.” Mr. Tauzin, a Louisiana Republican, is chairman of the Committee on Energy and Commerce, which has authority over Medicare payments to doctors.

The House bill would increase Medicare payments to hospitals by $14 billion over 10 years. Hospital lobbyists are seeking twice that amount in the Senate, to help them cope with a shortage of nurses, rising numbers of uninsured and the new threat of bioterrorism.

I guess that I must go back to Congress watching.

The Medicare drug debate will not go away

New twist in Medicare debate. Remember Yogi! It ain’t over ’till it’s over.

Doctors and politics

Doctors inject political influence into laws

America’s doctors, stung by rapidly rising malpractice insurance costs, are seeking to become a more potent political force in state legislatures across the country.

From West Virginia to Nevada, doctors are picketing, protesting and running for political office in greater numbers than ever. Some are even withholding services. The most recent example is in Philadelphia, where more than 300 doctors shuttered offices one day last week to attend a conference on medical malpractice issues.

That’s behavior rarely seen before by doctors. Some hope that by becoming politically active, they can influence issues beyond medical malpractice, such as Medicare’s solvency and prescription-drug costs.

“It’s completely weird for physicians to be doing this,” says Weldon Havins, CEO and special counsel for the Clark County Medical Society in Las Vegas. “Doctors are competing with lawyers who have, from their first day of law school, been trained and are aware of the political process and the importance of law. Doctors have absolutely zero training with that.”

What an interesting trend! In my own mind I have often contrasted medicine and law. If this trend continues, we will all have to consider this contrast. At the risk of becoming pedantic and one sided I will share my concept.

Medicine involves a search for truth. The scientific method provides the basis of our decision making – what is the true diagnosis and what therapies really help. While we do not always succeed either in caring for individual patients or in finding the right principles (examples here include estrogens to prevent heart disease, antiarrythmics after myocardial infarctions), we are willing to reexamine our principles and methods – and then change to a better method.

In contrast I see law as advocacy. Legal methods include sophistry. The desired result is to win – regardless of truth. Lawyers are indifferent to truth – and define truth as their ability to influence the jury. While this characterization includes some hyperbole, it is not that far from truth.

If my formulation makes sense, then logically we would like physicians as legislators. They should look at issues searching for the best and most logical course – weighing all the pluses and minuses. I fear that politics being what they are, they too will succumb to the desire for power and reelection. But just maybe, they would do a better job. You will allow this general internist his dream won’t you.

The health care crisis

We clearly have a health care crisis. Traditional politics are not solving the crisis. A weakened economy exacerbates the crisis. Read these reports – State budget cuts reduce flu vaccine stock for winter. This report comes from Boston

The Department of Public Health cut its purchase of flu vaccines by 19 percent this year – 132,000 doses – but the reduction is hardly catastrophic. With 560,000 doses expected to be on hand by November, state officials said yesterday they will not refuse anyone requesting vaccination at a state-run clinic.

The state public health department initially requested 700,000 doses costing $22 million based on vaccine use in 2001, a year when the threat of anthrax and its much-publicized flulike symptoms led to record immunization requests. The Legislature, contending this year with a slowing economy and dwindling tax revenue, budgeted $20 million for adult vaccines, $2 million less than the public health department’s request.

Children’s vaccine stocks, maintained separately from adult stocks, are unaffected by the funding reduction. But state supplies of vaccine for pneumococcal disease and hepatitis A and B will also be cut, though state officals yesterday did not release specifics.

State vaccine supplies account for about half of all flu immunizations in Massachusetts; the rest are administered by private health providers. State officals have traditionally targeted the elderly for vaccination. Those with kidney and blood diseases have also been the focus of past outreach efforts.

DeMaria said the state will urge community clinics to use their vaccine allotments on the elderly and the sick first.

California also has problems as noted in these two articles – A Messy Miracle for the ER

In a miracle of resuscitation, the state Legislature on Saturday approved a new way to pay for California’s ailing emergency-care system. How it happened was messy, but the outcome is hard to fault.

Senate Bill 807, which now awaits Gov. Gray Davis’ signature, would help pay for emergency care by adding a $200 surcharge to fines for reckless driving, speeding and drunk driving. It’s almost a user fee, since so many of these folks end up needing trauma care.

The money raised–projected at $25 million–wouldn’t cure the state’s health-care woes; neither would it lift the pressure from Los Angeles County. But it would prop up the system facing the most immediate crisis, the one that all of us count on in the event of an accident injury or a heart attack.

If Hospitals Close, Research Flat-Lines : Funding crisis in Los Angeles County threatens clinical studies. I write about health care costs regularly. We need good medical input on understanding costs. Politicians do not have the answers. Talk to generalists, physicians who provide the important overall care of patients. They can help us understand how to address these issues.

The politics of a Medicare drug benefit

The NY Times features an article on the political implications of drug costs for the elderly – In an Election Year, These Protesters Have Power. In many ways this will probably become a major ‘single issue’.

The Senate deadlock resulted from divisions over costs and levels of coverage, as well as whether such a program should be run by Medicare or the private sector. A poll of 1,071 adults 45 and over, conducted by AARP from July 31 to Aug. 4, immediately after the Senate deadlock, found considerable concern about the issue. More than 60 percent of those surveyed said that prescription drug benefits were a “very important” issue and that they were “angry” or “very angry” that the two parties could not reach an accord.

The same percentage said they were more likely to vote for their senator if he or she supported a prescription drug plan; more than 25 percent said they would vote against their senator if he or she allowed partisan differences to thwart the legislation.

Advocacy groups are marshalling energy over this issue. They are surveying voters and trying to crystallize a position. Financial realities do not matter to those groups, they want their program!

For Mr. Hickey and the groups with which he is aligned, a good bill would set up a price-controlled prescription drug program run by Medicare that covers all drugs for all older Americans and is not “means tested,” or linked to income. That is pretty much what most Democrats want. The problem is that it could cost $800 billion or more over 10 years.

Drug companies object to price controls, and most Republicans and some conservative Democrats want a program run by private insurance companies and with limited coverage. That position is best reflected in a Republican bill passed by the House. In that version, there would be coverage for part of drug costs up to $2,000 a year, but then people would be on their own until costs reached $3,700 — a gap that critics call the hole in the doughnut.

The wild card in all this is rising drug costs. Families USA, a consumer advocacy group for health care issues, says the prices of the 50 most prescribed drugs for older adults rose, on average, by nearly three times the rate of inflation last year. The group criticizes big drug makers, saying they pay high executive salaries and spend about twice as much on marketing, advertising and administration as on research and development of drugs.

Jeff Blum, executive director of US Action, an advocacy group, argues that the public is far ahead of elected officials in linking access to drugs with cost control. “People know if there is not some serious controlling of drug prices, they’re not going to get the benefit of a prescription drug program,” he said.

Of course many would prefer avoiding means testing. The cost of a ‘free’ program would be very difficult to afford. The pharmaceutical companies will probably lost a battle here on price controls. I wonder if a true compromise will satisfy the activists?

Medicare reform still likely

This from the AMA News = Senate debate shifts to pay fix: A panel plans to consider reversal of Medicare physician reimbursement cuts next month, but reaching agreement on a prescription drug benefit could be trickier. Perhaps some good news is coming.

Although details of the payment package were not available at press time, the overall spending level of the measure is expected to be close to the $30 billion over 10 years approved by the House in June. The House measure included $21.3 billion over five years to replace the deep cuts in physician reimbursement predicted for the next three years with payment updates of about 2%.

Meanwhile, the body of evidence showing that physician payment cuts are causing an access problem for Medicare services is growing. An annual survey by the American Academy of Family Physicians found that 21.7% of its members can no longer take new Medicare patients, up from 17% in 2001.

“My practice has been forced to quit taking new Medicare patients because the costs associated with treating them are increasing, while our reimbursement continues to go down,” said Deborah G. Haynes, MD, a family physician from Wichita, Kan. “It’s sad, because these are the patients who need us most.”

Amen!

Medicare drug plans – a discourse

Michael Kinsley makes sense (my fingers deceive me). He has analyzed the debate over prescription drug benefits rationally. Congress on Drugs: The bizarre debate about a prescription drug benefit. He asks

Government benefit programs are sometimes called “social insurance,” but what exactly is being insured against? Look at the prescription drug benefit that died—for this year—in the Senate on Wednesday. Differences between this proposal and the one that passed the House in June do not loom large to the naked eye. Both parties claim to favor drug coverage for the elderly, and what they are quarreling about is as unclear as the philosophical basis for the plans they have come up with.

Hey Michael – they are quarreling about politics. Just thought you would want to know.

When Congress takes up a drug benefit again, it should keep things simple and concentrate on the risk, approaching a certainty, that it wishes to prevent: people doing without drugs—or without food—because of the cost. That means concentrating on poor people. The risk that drug prices will move you down a notch in the middle class is not something an entire society can insure itself against anyway.

Amen!

No patient’s rights bill this year

I generally respect and like this administration. They have this one wrong. I generally dislike the trial lawyers, but they may have this one right. White House and Senate Hit Impasse on Patients’ Rights

In June last year, by a vote of 59 to 36, the Senate passed a bill that would establish a wide variety of patients’ rights for more than 200 million Americans. Patients could file suit, in federal or state court, to enforce their rights and could win damages for certain injuries. President Bush had threatened to veto the Senate measure, but supported a bill passed by the House last August. The House bill would provide patients with a much more limited right to sue.

No surprise – Senate deadlocks

When you keep expectations low, your do not get as disappointed. Senate Kills Plan for Drug Benefits Through Medicare

Senators of both parties said they would have to answer to voters this fall for their failure to deliver Medicare drug benefits. Each party blamed the other today.

They continue to posture, spin and not address issues. Blecchh!

A good political idea

As a physician, Senator Frist champions medical care. He also champions prevention. Senators Take Up Arms Against Obesity.

“Obesity is, for the most part, preventable,” said Frist, R-Tenn. “There is no single solution, but better information, improved nutrition and greater opportunities for physical activity will guarantee progress.”

To provide those resources, the three senators are proposing spending as much as $217 million next year and additional money in future years on a variety of programs to encourage proper nutrition and increased physical activity.

The money would go to the Institutes of Medicine, the Centers for Disease Control and Prevention and the Department of Health and Human Services to identify risk factors, analyze government food assistance programs and work with state governments on nutrition and exercise programs.

While I generally oppose government solutions, government funding can stimulate great research. On the surface this sounds like a well placed effort.

Will the fat lady sing?

Or as Yogi once said, ‘It ain’t over until it’s over’. The Senate will apparently try again today. I won’t bore you with the details unless the bill passes – Big Senate Vote on Medicare Drug Benefits Is Set for Today. Passage is doubtful.

Senate persists on drug plan

Being a doctor makes so much sense. Being a politician …

The posturing has occurred; the political points made; now the compromising begins. Apparently, we do have a reasonable chance for Medicare drug benefit – Senators Scale Back Drug Proposal. Did we not really know this all along?

The compromise is a retreat from Democrats’ longtime push for a comprehensive benefit that covers all senior citizens. But it also omits Republicans’ push to have a plan that relies on private insurers. The compromise calls for a benefit administered through Medicare, according to one Senate Democratic aide, who spoke on the condition of anonymity.The proposal would cost between $400 billion and $450 billion over 10 years and would cover about half of the 40 million senior citizens on Medicare, Kennedy said. That’s substantially smaller than the $594 billion plan Democrats unsuccessfully brought to the House floor earlier this week. That plan, as well as a $370 billion proposal offered by a coalition of Republicans, a Democrat and the Senate’s lone independent, failed to get the 60 votes necessary for passage.

We are probably getting to the right place. Those senior citizens who can afford the medications do not need our subsidies. The poor need our help. I wonder if the plan could actually save some money. How many preventable hospital admissions come from financially induced drug non-adherence? Whether that speculation makes the true amount smaller, a compromise plan seems the right thing. More this week.

No surprise – Senate deadlocks

Everyone wants a Medicare prescription provision. Each party wants their own – Two Parties’ Plans on Prescriptions Falter in Senate

Today’s votes, the most significant in a two-week Senate debate on prescription drugs, were the latest illustration of the deep philosophical differences over the proper role of government in meeting one of the nation’s greatest social needs.Democrats wanted the government to establish uniform drug benefits, while Republicans wanted the government to pay subsidies to private insurers to provide coverage for drug costs, with insurers allowed to vary premiums and other details.

“We are not going to give up,” said the Senate majority leader, Tom Daschle, Democrat of South Dakota. “Everything is on the table. If we can find a role for the private sector, for the insurance industry, I would not be averse to doing that.”

Likewise, when asked if he would consider a proposal to provide drug coverage just to Medicare beneficiaries with low incomes or high drug expenses, Mr. Daschle said, “I’m not averse to that.”

But Senator Edward M. Kennedy, Democrat of Massachusetts, said he would prefer not to make such concessions in a program that provides health insurance to virtually all the elderly, regardless of income.

So instead of compromise we have posturing. Instead of compassion we have politics. But then, this is what we expected.

The latest on the Medicare drug benefit

Senators Ready to Vote on Proposals While the are ready, there is no apparent compromise in sight. Many remain skeptical

Senate Minority Whip Don Nickles, R-Okla., said over the weekend he was afraid the Senate might not be able to pass a bill. “I’m afraid that might happen,” Nickles said on CBS’ “Face the Nation.” “I hope not. I hope that we can pass something.”A spokesman for Finance Committee Chairman Sen. Max Baucus, D-Mont., conceded Monday that a compromise could take some time.

“Our commitment to this issue is to get the right bill,” said Michael Siegel. “We’re operating under no self-imposed deadlines, which means we could be at this well beyond this week.”

I hope that they can develop a reasonable compromise.

Senate passes a drug Medicaid bill

Despite heavy opposition from the pharmaceutical industry, the Senate Votes to Expand Drug Cost Cuts Of Medicaid.

Senator Debbie Stabenow, Democrat of Michigan, the chief author of the proposal, said it was meant to encourage state efforts to make prescription drugs more affordable. “We are saying yes to the innovation of the states,” Ms. Stabenow said.The Pharmaceutical Research and Manufacturers of America, a trade group for brand-name drug companies, has gone to court to stop drug discount programs adopted in Maine, Vermont, Florida and Michigan, among other states. The organization denounced Ms. Stabenow’s proposal, saying it could embolden more states to try to control drug costs by restricting access to certain medicines for low-income people.

Daily political update

I hate this, I really do. How the Senate compromises on the prescription drug crisis has major implications to how we provide patient care. Thus, while I hate the posturing and attention to special interests, I feel obliged to read this stuff. So for your aggravation – Senate Divided Over Rival Plans For Prescription Drug Coverage

In recent days, Democrats, Republicans and a bipartisan coalition have laid out new proposals, and each side is scrambling to pick up supporters with public rallies, behind-the-scenes negotiations and one-on-one lobbying of colleagues. But, even as debate began, senators conceded that none of the proposals has enough votes to pass, creating the risk of a stalemate that would leave older Americans without help for another year.

Politics and prescription drugs

No surprise to me or readers of this blog, politics are stalling the debate on the generic drug proposal and the Medicare prescription drug plan – Prescription Drug Debate Stalled

The dispute came as lawmakers scrambled to get enough votes for three competing Medicare prescription drug proposals, none of which currently has the 60 votes needed for passage.Two Republicans, Sens. John Ensign of Nevada and Chuck Hagel of Nebraska, entered the fray Monday by offering a 10-year, $160 billion proposal, the least expensive so far.

That plan relies mostly on a Bush administration proposal to have seniors buy private discount drug cards at $25 a year for savings. Government help would kick in once a senior citizen reached limits set according to income. For instance, the poorest seniors would have a $1,500 cap. After the cap was met, a beneficiary would pay no more than 10 percent of the cost of each prescription.

As predicted, we won’t get much intelligent debate, but rather much politics.

Maybe some Medicare payment relief

The AMAnews reports Doctors closer to Medicare pay relief: An administrative change adds new funding as the House passes a Medicare payment fix.

Physicians won’t be too upset that Medicare officials don’t think they’re as productive as previously assumed.By downgrading its estimate of physicians’ ability to increase their income by being more productive, the Centers for Medicare & Medicaid Services has proposed restoring more than $1 billion in physician Medicare payments through 2005.

The change was announced just as the House of Representative voted 221-208 to adopt a Medicare reform package that included a prescription drug benefit and a three-year fix of the physician payment update formula. The measure would eliminate deep cuts in Medicare payment rates, setting the update at about 2% for each of the next three years.

Well this could help a bit. The politics of Medicare payments continues in the Senate this week. More as I find links.

The politics of pharmaceuticals – now the Senate

Michigan Senator Will Lead Democrats in Prescription Drug Debate Senator Stabenow frames the problem

“We have an industry that is the most profitable in the world,” Ms. Stabenow said. “And I don’t begrudge that in any way. But when an industry is allowed to make 18 to 20 percent a year, at the same time it’s raising prices three times the rate of inflation, and people who need life-saving medicine cannot afford it, I think it’s time to ask where the corporate responsibility is.”

As one would expect the pharmaceutical industry responds

Brand-name drug makers oppose the bill to speed the marketing of generic drugs. They say it would undermine patent protections, reducing incentives for the discovery of new treatments beneficial to patients. Generic competition often causes precipitous drops in sales of brand-name products.Drug companies also oppose efforts to import cheaper prescription drugs from Canada. Inevitably, they say, such imports will include products that are counterfeit, contaminated, adulterated or misbranded.

More from the Senator

Although Ms. Stabenow has spoken to Mr. Holmer and other drug company representatives, she said: “I’ve gotten more and more frustrated because they fight everything. I would love to find a way to work together on something meaningful. But they have the financial capacity, and a financial incentive, to fight everything, because so much money is at stake.”Mr. Holmer said that the drug industry favored Medicare coverage of prescription drugs, “offered through competing private insurance plans that rely on marketplace competition to control costs.”

Ms. Stabenow said such coverage would be unreliable and unstable, like the coverage provided by health maintenance organizations. Many H.M.O.’s have found federal payments inadequate and pulled out of Medicare, dropping 2.2 million beneficiaries since 1998.

While I generally lean towards the conservative Republican position on economic issues, this one is different. I see what tactics the pharmaceutical industry uses, and how those tactics effect patients. The industry does good research, and without a strong pharmaceutical industry we could not care for our patients as well. However, this time I seem to side with the Senator. Obviously, I will be following this debate closely.