Tuesday, June 23, 2009

Insurance Industry Buys Politicians - Probably

FiveThirtyEight.com has a great post with a pretty graph about the likely effects of the amounts of money the insurance industry spends on politicians. The largest receiver of bri... contributions is Baucus, the guy leading the health care reform decisions, and who is opposed to a public insurance option.

FiveThirtyEight continues to be clear and responsible, pointing out that it did not take into account counter-lobbying from unions and other pro-public-option factions, and also that it is hard to tell if "perhaps senators receive a lot of money from the insurance industry because they hold conservative positions on health care, rather than the other way around. Although I believe that accounting for ideology should correct for most of this".

Thursday, June 18, 2009

HR 676 - The Good and the Bad - Part 5

Continued from Part 1, Part 2, Part 3, and Part 4.
"Non-profit health maintenance organizations that actually deliver care in their own facilities and employ clinicians on a salaried basis may participate in the program and receive global budgets or capitation payments as specified in section 202."
"Other health maintenance organizations, including those which principally contract to pay for services delivered by non-employees, shall be classified as insurance plans. Such organizations shall not be participating providers, and are subject to the regulations promulgated by reason of section 104(a) (relating to prohibition against duplicating coverage)."

So, these sections serve to clarify how different HMOs will be treated. Non-profit HMOs that provide care will be treated as service providers that can qualify for reimbursement by the federal plan. Other HMOs will be treated as insurance plans.

This probably has to do with cost containment and standardization, making it easier to prevent outsourced and possibly for-profit doctors or clinics from indirectly charging the federal plan for services that would be harder to efficiently monitor. We're still on section 103, and have not gotten to the later sections that explain payment more thoroughly. On the face of it, this seems potentially unnecessarily restrictive, and may strong-arm doctors to become salaried or capitated employees of non-profits. I admit to an incomplete understanding of HR676's rationale for requiring salaried or capitated providers. I will explore different payment types and their consequences in the future.

"Patients shall have free choice of participating physicians and other clinicians, hospitals, and inpatient care facilities."
Most hospitals will be participants from the beginning. Many more will make the transition. Most people who already have health insurance are already familiar with "in-network" versus "out-of-network" providers, so this idea will not be confusing. The difference will be that "in-network" with HR676 means most facilities throughout the whole country.

Freedom of choice will also put pressure on facilities to be more competitive with regard to quality. Since services will be free to people under HR676, service differentiation (covered services) will involve quality instead of price. Low quality providers will be less able to rope in clients by cutting deals with third-party payers.

I am at a loss.

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National Center for Complementary and Alternative Medicine

USA Today had an article on the progress of the NCCAM over the last ten years. The federal agency funds research into the effectiveness of complementary and alternative medicines. The conclusion: $2.5 billion of research shows us that almost none of that stuff works better than placebo.

The tone of the article suggests that NCCAM is bad for spending so much of our money studying stuff that doesn't work. Really, it is only partly bad, and that is due to the agency's implementation. It is important to know what works and what does not work. If no one else is going to do the research (because there is no incentive, because CAM is underregulated), then it is good that NCCAM is picking up the slack.

Where NCCAM falls short is in telling us all that these things do not work. With a board loaded with CAM supporters, the conflicts of interests are apparently too strong to allow the agency to work the way it was intended. It is not spreading the message that bogus "supplements" and "remedies" are bunk, and there is no regulatory authority to ban these misleading products and treatments that take advantage of the ignorant.

It also falls short in that it continues to research absolutely ridiculous things, such as distance healing and energy fields. It wasn't good when the military looked into psychic detection of enemy submarines, and it's not good to waste money on this complete malarky now. Until someone gets James Randi's prize, the feds should stop wasting tax money in these directions. There are a lot of things we already know don't work.

Double-blind, placebo-controlled, randomized study is the standard when possible. Never trust someone who is trying to sell you something. Our country would be better off if our government protected people who just don't know better from snake-oil salesmen.

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Tuesday, June 16, 2009

Health Care Related Bankruptcy

A report on NPR about a Harvard study relays some very interesting information.
"In 2007, 62 percent of all personal bankruptcies were linked to medical bills. That's nearly 20 percent more than reported in 2001. And in most cases, those who sought bankruptcy protection had middle-class earnings; nearly 80 percent were covered by health insurance."

Making methodological adjustments, the researchers give alternatives for the 2007 proportion of bankruptcies caused by medical problems: 44% or 69%.

This highlights the problem of underinsurance. Having some of the health insurance plans currently available does not guarantee financial security during an medical problem. Making insurance mandatory will not fix these problems. Only by dictating higher minimum standards of affordable insurance can people be protected. But the insurance companies don't want that, and free-market ideologues don't want that. They would rather have rich shareholders and deregulation than a healthy and productive society that won't fall apart when some people get sick or injured.

I can't help but wonder how much of our current economic crisis could have been prevented or mitigated by a government-provided health insurance plan comparable to other industrialized nations, since it would have prevented a huge number of loan defaults. Maybe it just would have delayed or dragged out a recession of the same severity, or maybe it would have given us more time to analyze and respond to a smaller version of what we got.

Thursday, June 11, 2009

Infant Mortality Revisited

Continuing from before. An article on the ABC news website discusses factors related to infant mortality in Memphis, TN, which has the highest infant mortality rate among US cities. The article also reminds us that the US has the highest infant mortality among the 23 richest countries in the world.

"Premature birth is the primary medical cause of infant mortality." American doctors try really hard to turn premature births into living babies, spending massive resources on NICU treatment, then sending them home to still die at high rates compared to other wealthy countries. I used to challenge international infant mortality comparisons on the basis that other countries didn't include deaths of babies born after less than, say, 30 weeks gestation, while the US counted anything over maybe 24-27, depending on who's reporting. Lately, though, the comparisons have been careful to use the same gestation criteria across countries, I think with five hold-outs. What I do not know is the proportions of births by country that are premature. If America has higher rates of premature births, that could explain much of the higher infant mortality rate.

I believe that race washes out as a factor when the model includes SES, parenting, education, religion, and geography. Children develop into healthier, smarter, better-thinking people when they have affectionate, stable parents. Girls who grow up without dads, or without affectionate parents, make bad decisions about relationships, and are more likely to get pregnant early by another poorly raised teen or an exploitative adult. Remember to look at this model pangenerationally. The young people having kids that survive are the bad parents of the next generation of young parents; with poor brain development, making bad decisions, working poor jobs if at all, poorly educated, stressed out because they are incapable of managing effective lives. Religion contributes to ineffective education about birth control, and to preventing abortions. It is notoriously difficult for teens to get abortions in some areas of the US (like the South), so many babies are born to parents who do not want them and/or are completely unable to properly raise them. A recent TIME magazine chart showed that the South and Southwest have vastly higher teen pregnancy rates compared to other regions (New England has the lowest), and the chart was nearly identical to the earlier chart on infant mortality. Despite the media frenzy about the Massachusetts "pregnancy pact", the teen pregnancy rate in that area is very low for the US. Interestingly, mortality is only higher for the first-born of teens.

What can we do?
Obviously, a good start would be to get the areas with the worst problems to do more of what the areas with the best outcomes do. It blows my mind that the South wallows in problems while trash-talking New England. It also blows my mind that America wallows in problems while trash-talking Europe. Stop being blindly arrogant. Look at the outcomes. Apply best practices. Stop abstinence-only sex-ed. Promote safe sex. Provide social services that work. Make welfare-recipients buy vegetables (make them accessible, too) instead of chips and cigarettes. Make abortions and condoms accessible to teens. Provide drug rehabilitation instead of throwing addicts in jail. Provide incentives for the populations of people who can't make good decisions and resist being told what to do, so that they are more subtly influenced to do what is good for them. Not only would these things reduce infant mortality, but also reduce teen pregnancy, crime, and poverty, increasing national productivity and overall quality of life for the citizens of our country.