Health Wonk Review #24 is up

Jane Hiebert-White has posted HWR #24 at the Health Affairs Blog.  Excellent reading, as usual. 

I will be hosting Health Wonk Review #25 here at HealthBlawg on February 8, so please keep this in mind over the next couple of weeks and submit the wonkiest health care posts you read or write before 9 a.m. February 7 through the HWR blog carnival submission page.

Bonus general wonk question:  For HWR #25, can you tell us the subject matter of the 25th Amendment to the U.S. Constitution?

David Harlow

Universal health care coverage on the agenda

While some have seen the Massachusetts universal health care experience thus far as an experiment that can’t really be exported (see Boston Globe article from last April, just after passage of the law), it seems the local experiment has gotten a fair amount of attention and has triggered proposals in a number of other states. 

The two most recent are California and Pennsylvania.  Dr. Mark Smith, president and CEO of the California HealthCare Foundation and Dr. Stuart Altman, director, Institute for Health Policy, The Heller School, Brandeis University discussed this phenomenon on NPR a couple of weeks ago, and we will hear from the president on the issue of expanding health care coverage as part of his State of the Union address tomorrow night.  (See preview of this point in the NY Times.) 

While the conventional wisdom a few months ago was that health care ranked a distant third or fourth, at best, among issues important to the electorate, it seems to be top-of-mind for many elected officials right now.

David Harlow

It's the deficit, stupid

Warning against complacency over the federal deficit, Ben S. Bernanke, the Federal Reserve chairman, said Thursday that recent positive trends on the budget were a “calm before the storm,” masking a long-term danger posed by looming deficits in Social Security and Medicare.

“The longer we wait, the more severe, the more draconian, the more difficult the adjustment is going to be,” Mr. Bernanke said in response to a question at a Senate hearing about when lawmakers should tackle the growth of spending in the twin entitlement programs. “I think the right time to start is about 10 years ago.”

That’s the lead from the NY Times on Bernanke’s sobering testimony last week before the Senate Budget Committee.  One of the striking things he said was this:

According to the CBO projection that I have been discussing, interest payments on the government’s debt will reach 4-1/2 percent of GDP in 2030, nearly three times their current size relative to national output. Under this scenario, the ratio of federal debt held by the public to GDP would climb from 37 percent currently to roughly 100 percent in 2030 and would continue to grow exponentially after that. The only time in U.S. history that the debt-to-GDP ratio has been in the neighborhood of 100 percent was during World War II. People at that time understood the situation to be temporary and expected deficits and the debt-to-GDP ratio to fall rapidly after the war, as in fact they did. In contrast, under the scenario I have been discussing, the debt-to-GDP ratio would rise far into the future at an accelerating rate. Ultimately, this expansion of debt would spark a fiscal crisis, which could be addressed only by very sharp spending cuts or tax increases, or both.

Testimony of Chairman Bernanke from the Fed’s website.

There is a so-called "soft" trigger — under the Medicare Modernization Act — which will require the President to propose Medicare cuts if Medicare projections next year repeat this year’s projection that Medicare expenditures will exceed dedicated revenues by more than 45%.  This year’s projection sees that coming in 2012.  If there is another such projection in next year’s Medicare trustees’ report, then that so-called soft trigger will be pulled.  See the Health Affairs Blog post on this topic from last month, the testimony of the Comptroller referenced in that post (esp. pp. 9-11), and the GAO report referenced in that testimony.

Bernanke clearly does not expect the soft trigger, on its own, to magically do the trick.

About twenty years ago, the deficit spending of Reaganomics sparked a similar crisis and motivated the passage of the Gramm-Rudman-Hollings balanced budget amendment, which seemed like a worthy effort — Congress trying to control its own profligate spending.  It was challenged in the courts and ruled unconstitutional because of the automatic cuts built into the law.  It was revised and later replaced by other balanced budget legislation — all in all, an appealing idea at some level but, in the end, a failure as a policy matter.

Ultimately, the so-called "soft" triggers don’t really work, because there is always a political reason to approve more spending rather than less.  Exhibit A: uniform Congressional disregard for the Sustainable Growth Rate (SGR) formula that is supposed to limit Medicare reimbursement for physician services — Congress has overruled itself annually, so the SGR moderation of expenditures has never actually taken effect.  (See relevant HealthBlawg posts here and here.)            

It may be difficult to construct a "hard" trigger that would pass Constitutional muster, but that certainly seems to be what we need — and desperately.  If our elected representatives do not do so, or if they do not otherwise face the grim facts laid out by Bernanke (or other economists who suggest that rules about retirement age, Social Security and Medicare entitlements need to be rethought at a more fundamental level given changes in life expectancy — see, e.g., discussion towards the end of a recent Open Source radio show), then we will be staring down an intractable problem in the not-too-distant future. 

David Harlow

First 100 hours agenda item – House passes Medicare prescription drug negotiation requirement

The House of Representatives has passed part of the Democrats’ "first hundred hours" agenda (follow along at home, via Speaker Nancy Pelosi’s website), the provision that eliminates restrictions on CMS negotiating process for pharmaceuticals covered by Medicare Part D.  See earlier related HealthBlawg post here.

Update 4/18/07: The Senate deep-sixed the Part D price negotiation provision.

David Harlow

Federal appeals court upholds Wal-Mart win over Maryland "fair share" employee health benefits law

The NY Times reports that Wal-Mart won its appeal to the Fourth Circuit, arguing that Maryland’s fair share law was pre-empted by ERISA.  Further discussion of the law and the lower court ruling may be found in an earlier HealthBlawg post

Update 1/21/07: Read full opinion of Retail Industry Leaders Assn. v. Fielder (4th Cir., Jan. 17, 2007) here.

David Harlow

Disruptive physicians and medical apologies

The Joint Commission (i.e., The Organization Formerly Known As JCAHO) is field-testing standards on disruptive behavior.  The working draft provides some insight into the Commission’s thinking; the elements for performance to this standard are as follows:

1. The leaders develop a code of conduct that applies to everyone who works in the organization.

2. The code of conduct defines desirable and disruptive behavior.

3. All who work in the organization are educated about both desirable and disruptive behaviors.

4. The leaders develop processes for managing disruptive behavior.

5. Leaders identify the roles of individual leadership groups in managing disruptive behavior.

6. The organized medical staff manages disruptive behavior exhibited by physicians or individuals who are granted clinical privileges.

7. Leaders establish a fair hearing process for those who exhibit disruptive behavior.

While noble, the sentiments behind these standards are not brand new.  In fact, a JCAHO standard, circa 2001, touched on these same issues and was addressed, for example, by the Massachusetts Board of Registration in Medicine by promulgation of its own related policy.  Apparently the lighter touch of the earlier standards (which is sometimes extremely important in trying to deal with difficult personalities who are also brilliant clinicians) has proven to be insufficient to deal with the sometimes intransigent issue of disruptive physician behavior.

A tip of the hat to Michael Cassidy at Med Law Blog for noting the proposed standard change.

Unfortunately, disruptive physicians may also be, at times, physicians involved in medical errors.  I heard a terrific piece on NPR a while back on apologies — exploring the question of whether apologies are a good idea, from both psychological and risk-management perspectives.  This is, of course, a hot topic these days (check out The Sorry Works Coalition).

Update 1/25/07:  A Healthy Blog posted yesterday: "Doug Wojcieszak, the founder and spokesperson for the SorryWorks! Coalition, spoke at Health Care for All about apology and disclosure following adverse medical events."  Doug’s slides are up at A Healthy Blog. 

Double hat tip to Michael Cohen at CAM Law Blog (a fellow Bay State blogger) and Daniel Goldberg at The Medical Humanities Blog for highlighting Marlynn Wei’s law review article in press on medical apologies (link to abstract and downloadable PDF).  The article explores whether insulation from legal liability exists under state laws out there, and whether existence of these laws promotes apologies.

Civility certainly ought to be promoted, whether through sanctioning disruptive physicians or through encouraging apologies where mistakes have been made.  Given the increasing availability of provider quality report cards and the like, and the increased ability of consumers to decide where to get their care (thanks to health savings accounts and other consumer-directed health care initiatives), civility is not simply an ethical goal, it should be recognized as a bottom-line business goal as well.

Update 4/13/07: More states are considering medical apology laws.  Check out the AP story here, which includes a discussion of laws already on the books as well.

David Harlow