Last Call for Alcopops In MD?

Join Together, Boston University’s addiction research and advocacy program, reports that lobbying efforts from Mothers Against Drunk Driving (MADD) persuaded the governor of Maryland not to sign a bill that provided favorable financial treatment to “alcopop” drinks. Alcopops are heavily flavored alcoholic beverages that the alcohol industry uses to target young people (they prefer to call them “entry level” drinkers.) The early alcopop brands included “Zima” and “Mike’s Hard Lemonade,” but new products are leveraging the popularity of youth-oriented energy drinks.

MADD might find the insurance industry a useful ally in its efforts to restrict the sale of these drinks. I wonder if anyone’s thought of that yet?

Recent products have been packaged to resemble youth-oriented energy drinks. The Marin Institute prepared the photo shown above to demonstrate how drinks like “Sparks” and “Rockstar 21″ (”party like a rock star”) resemble teen-oriented caffeine beverages like “Monster” (with its “BFC” designation for “big “f**king” can.”) They’re being priced more cheaply than non-alcoholic energy drinks to exploit that market. And, as one teenager reports in the Marin Institute study (warning: pdf), “… my mom found it, but she had no idea and thought they were just energy drinks.”

MADD and other advocacy groups have targeted laws that allow alcopops to be designated as beer rather than alcohol. Beer is typically taxed at a much lower rate than other alcoholic beverages, and can be sold in many places where others can’t. The Marin Institute describes a three-point plan to target kids as a market for alcohol:

1. Create brand confusion with nonalcoholic versions
2. Provide a cheap alternative to mixing energy drinks with alcohol
3. Deploy youth-friendly grassroots and viral marketing

The Maryland bill addressed taxation only, not sale, and the governor agreed only to delay it. The bill was pushed by the alcohol lobby, which is politically well-organized. That’s why a strategic alliance between MADD and the insurance industry might make sense. After all, when teens are injured or killed as a result of alcohol-related accidents, it’s insurance companies who typically pay the bill. Their pockets are deeper than MADD’s, and their political connections are better.

The etiology of alcohol addiction is still unclear, so it can’t be said definitively that ‘alcopops’ contribute to alcoholism rates. But it could certainly be argued that they contribute to increased episodes of drunkenness, and therefore injury and death. It could also be argued that kids with a predisposition to alcoholism might experience an earlier onset of the condition as a result of these drinks and their marketing strategies.

MADD and America’s Health Insurance Plans, plus MADD and the American Insurance Association: Two matches made in heaven? It could cut into teen death and injury, and the health insurance industry might want a little good publicity right now.

“Universal Coverage” - Only Words

It’s only words, but words are all I have to steal your heart away …¹

My wife and I stood at the curb saying goodbye to our friend Maureen last week. The election came up, and Maureen said “I like the candidate that’s going to provide universal coverage.” Here’s the problem: there’s no such candidate this year. Maureen’s been had.

But first, a question: What’s wrong with this sentence, from my friend Joe Paduda’s informative write-up of the World Health Care Congress, referring to the difference between the Clinton and Obama health plans?

“… [Clinton] wants mandated universal coverage and [Obama] does not.”

The italics were a hint: Joe and I agree, as does our mutual friend Bob Laszewski, that the two plans are essentially similar. But their primary difference, which is that the Clinton plan includes mandates for adults, can not accurately be described as “universal coverage.” The Massachusetts experience has demonstrated that conclusively.

Even if a mandate plan were to be passed, millions of today’s uninsured would - by my estimation - remain uninsured. Millions more would benefit, as they would under a non-mandated plan, but we’d have nothing like genuine “universal coverage.” And many working Americans would face new financial pressures, without receiving better health coverage in return.  (My numbers and logic are laid out in a footnote.)

I expressed early and serious concerns about the Massachusetts plan, and there’s no pleasure in reporting that they have proved justified. The plan’s been very effective in providing coverage for those who qualify for full subsidies. But it has been far less effective for lower-income working people. Subsidies don’t reach them, and the difference between plan premiums and the mandated tax penalties they face is still a big-dollar amount for their budgets.

The result? These hard-pressed Americans still don’t have health coverage … and they’ve been hit with more taxes.

The Massachusetts plan is a lot like Clinton’s, in a state with a much less complex uninsured problem that other parts of the country - and it’s been forced to exempt 20% of the uninsured. That’s not “universal coverage,” it’s health mandates - and while it will provide coverage for some, many will fall through the cracks.

Why does this matter? Why am I harping on the choice of words? Because perception drives reality in politics. Maureen thinks her candidate will provide “universal coverage” if elected. Here’s what will really happen if Maureen’s favorite gets the nomination - she’ll be hammered by her opponent in the general election over the enormous added tax burden to lower-income working families. If she wins, her plan will face far greater political opposition because of the mandate provision - which will most likely be dropped as a result. If, against all odds, these obstacles are overcome and a mandate provision is passed,

Based on rough calculations, I agree that Obama’s plan would leave approximately 15 million uninsured. But I estimate that Clinton’s plan would leave 8 million uninsured - and is far less likely to pass in Congress.² (Each plan has its own strengths in the cost-cutting and health oversight areas - and McCain’s isn’t really a “plan.” It’s more of a “wealth-transfer-device” for the already well-to-do … but that’s another topic.)

What about the argument that a mandate plan can’t pass?

Not so, says Paduda. He quotes Obama surrogate Rep. Jim Cooper as saying the mandate provision - which Joe again mischaracterizes as “universal coverage” - will get “zero Republican votes,” which he calls “a completely wrong statement.” Joe cites the mandate-driven Wyden Health Plan, with six Republican co-sponsors, as proof.

But the Wyden plan, which takes employers out of the health insurance game, has a couple of carrots to offset the “mandate” stick. One’s for working people: It requires employers who currently provide coverage to boost salaries to offset for the huge expense savings they’ll get. That puts money back in people’s pockets. The second is for employers: Salaries are rising at a much slower rate than health premiums, and they have more control over them, so this is a financial win - especially for larger corporations.³

I’ve talked to many employers over the years - large and small - who would love to get out of the health benefits business. And I’d argue that the Wyden bill can be pitched as more attractive to lower-income working people. I suspect these differences make the Wyden bill GOP-friendly enough to offset for its universal coverage mandate provisions. (That said, it’s excessive of Rep. Cooper to suggest that a mandate bill would get “zero” Republican votes. There might be handful, but probably not enough to pass …)

So we watched Maureen pull away from the curb, content in her belief that at least one Presidential candidate would bring the country “universal coverage.” Can’t blame her: a lot of smart people think so, too.

Too bad life ain’t so simple …

_____________________

¹What would a wonkish health policy post be without quoting at least one Bee Gees song? Others I could have cited here include “Stayin’ Alive” - and, of course, “Massachusetts.”

²Quick and dirty calculation: Massachusetts, which is demographically less challenging than other parts of the country (fewer illegal immigrants, etc.), was forced to exempt 20 percent of the uninsured from its plan. Planners in more variegated California expected that 30% would have to be exempted. So, even the generous assumption that mandates will do as well nationally as they have in Massachusetts gives us a 20% exemption rate. If we assume 40 million uninsured nationwide, then 20% = 8 million. That ain’t universal. Thus, the difference between an Obama plan that excludes 15 million and a Clinton plan that excludes 8 million is 7 million.

What’s left to consider? First, whether you think a mandate plan can pass Congress. If it can’t, everybody loses. Second, your personal opinion of whether mandates for hard-pressed working families are a) a way to force them to pay their fair share, or b) another regressive tax that places too much burden on those at the lower end of the spectrum.

³Re the Wyden plan, I like the concept. Unfortunately, though, I can see a number of ways that employers could game it. But that’s for another day.

As The Sentinel Effect Goes, So Goes the New York Times

Yesterday we wrote this about the New York Times article on Tier 4 pharmaceuticals:

Defenders of the Tier 4 system will say that health premiums will become unaffordable if these costly treatments … are paid by insurance. There’s some truth to that. But here’s the problem with that argument:  The function of insurance is to protect individuals from expenses they can’t afford. Once you start withdrawing that protection, it’s a misuse of language to describe the product you sell as “health insurance” …if it isn’t really “insurance” anymore, what are they offering?

Yesterday’s post was called “When Is Health Insurance Not Insurance?” The New York Times ran an editorial about Tier 4 drugs today. Here’s an excerpt:

The insurers say that forcing patients to pay more for unusually high-priced drugs allows them to keep down the premiums charged to everyone else. That turns the ordinary notion of insurance on its head. Instead of spreading the risks and costs across a wide pool of people to protect a smaller number of very sick patients from financial ruin, insurers are gouging the sickest patients to keep premiums down for healthier people.

Coincidence? We report, you decide. But if the New York Times wants some more help with their editorial page then, believe me, I have some more suggestions …

Tier 4 Drugs: An Industry Response

Ezra Klein spoke with Robert Zirkelbach of America’s Health Insurance Plans regarding Tier 4 medications. Mr. Zirkelbach’s response hits a few points:

National Conversation

That we need a “national conversation” about “whether drugs that cost ten or a hundred times as much as current treatment options are producing better outcomes.” (Whatever your opinion of Hillary Clinton, I’m not particularly grateful for the insertion of the phrase “national conversation” into the political lexicon. A little less talk, a little more action, as Elvis would say.)

In this case, I would say we don’t need a “conversation” about better outcomes. We need data. It’s a research question, not a political one. If these therapies are better than the alternative, then we need a conversation - but it has to be about our level of willingness to provide insurance that pays for the best available treatment. That’s a debate worth having, and it’s also where we need some of that transparency Jonathan Cohn calls for.

Generic Alternatives

Mr. Zirkelbach says we should encourage “generic versions” of Tier 4 drugs. But, as Ezra points out, they’re not likely to be available.

Comparing New and Current Treatment Options

Lastly, Zirkelbach suggests “we need a national system in this country that compares new drugs with the treatment options currently available in the marketplace.” That’s a good point. Even under single-payer coverage, we would still need to do cost/benefit analyses on very expensive therapies - and not just for pharmaceuticals. The more information that’s made publicly available, and the more education and debate that ensues, the better.

I still say there is a point at which “insurance” becomes a misnomer. What that point may be is somewhat subjective, but in theory it’s this: When the coverage being provided no longer protects individuals from severe financial harm as a result of loss.

And I’d add this thought to the “national conversation”: When plan designs are no longer made to change behavior, but simply to transfer high-cost items back to the insured party, that’s risk transfer and not benefit design. As a result, the insurance concept is being subtly modified - and arguably undermined.

Tier 4 Meds: When Is Health Insurance Not Insurance?

Is health insurance even insurance anymore? The high cost of intensive drug therapies is being shifted back onto patients - and not because the procedures are considered “experimental.”

The New York Times’ Gina Kolata wrote a piece today about a new kind of financial catastrophe striking Americans who have - or think they have - health insurance. The problem is with so-called “Tier 4″ drugs, which are typically prescribed for severe medical conditions. These medications are extremely expensive, and insurance companies have been exempting them from the usual rules (like fixed copays and out-of-pocket limits) that protect their members from financial shock. As a result, people who think their they’re protected financially are being hit by huge drug bills.

Patients aren’t bearing more of the cost for these medications because they’re experimental - a reason that’s often used for denying certain treatments. They’re bearing more of the cost because they’re expensive, at least as far as some quick research today could determine. And, as Jonathan Cohn of The New Republic observes, the political debate isn’t even addressing this part of the problem.

How bad is it? Take one breast cancer patient in the Kolata piece, for example, who lives on Social Security disability and has Medicare coverage:

(Her insurer) declined to say what Tykerb might cost, but its list price according to a standard source, Red Book, is $3,480 for 150 tablets, which may last a patient 21 days. Wellcare requires patients to pay a third of the cost of its Tier 4 drugs.

That’s nearly $400 every three weeks. Or, how about the MS victim whose Kaiser coverage changed unexpectedly, so she didn’t find out until she picked up her usual prescription?

Now Kaiser was charging 25 percent of the cost of the drug up to a maximum of $325 per prescription. Her annual cost would be $3,900 and unless her insurance changed or the drug dropped in price, it would go on for the rest of her life. “I charged it, then got into my car and burst into tears,” Ms. Steinwand said.

Ezra Klein’s not sure how Tier 4 drugs are designated. (But he got curious about it, too. See his post and my reaction.) Ezra writes:

(Kolata’s) article vaguely implies that Tier Four is simply composed of costly drugs that insurers are dumping on patients. My understanding of the situation is that Tier Four is actually composed of largely experimental and unproven treatments that don’t seem to offer benefits in line with their cost. If it’s the former, then this really is, as the article seems to suggest, a cruel and crazed practice. If it’s the latter, then it’s exactly what we need to be doing.

I wish Ezra was right, but he’s not. Here are a couple of examples of the logic used to transfer these costs to customers. Blue Cross and Blue Shield of North Carolina says Tier 4 drugs are “medications classified by BCBSNC as those which require special dosing or administering, are typically prescribed by a specialist and are more expensive than most medications.” That’s it: nothing about “experimental.” And the UPMC health plan, affiliated with the University of Pittsburgh health system, says this:

The fourth tier is for specialty drugs, which are high-cost medications and biologicals, regardless of how they are administered (injectable, oral, transdermal, or inhalant). These drugs also have the highest level of copayment. These medications are often used to treat complex clinical conditions and usually require close management by a physician because of their potential side effects and the need for frequent dosage adjustments.

These two descriptions are typical of the way insurers describe Tier 4 drugs. Defenders of the Tier 4 system will say that health premiums will become unaffordable if these costly treatments, which can exceed $100,000/year, are paid by insurance. There’s some truth to that. But here’s the problem with that argument: The function of insurance is to protect individuals from expenses they can’t afford. Once you start withdrawing that protection, it’s a misuse of language to describe the product you sell as “health insurance.” It needs to be called “health cost offset,” or “selective health cost mitigation,” or something else that doesn’t promise more than it can deliver.

If costs have become so high that the private health insurance system can’t provide affordable coverage that protects people from financial harm, then the entire system needs to be re-envisioned. Remember: In all the debate about “universal healthcare,” most politicians are really talking about “universal health insurance.” But if it isn’t really “insurance” anymore, what are they offering voters?

(Kevin Drum has also written about this issue)

Are We Asking the Wrong Questions About Disease Management and Medicare?

A recent study suggests that Medicare’s Disease Management (DM) experiment has failed to cut medical costs. DM advocates argue that Medicare’s methodology was flawed. So what’s the answer? A New York Times article asks: Does Medicare DM cut costs, or should it be stopped?

That may be the wrong question.

As far the first part of the question is concerned, it wouldn’t be surprising if the answer turned out to be “no.” Revenues for disease management companies grew from $78 million in 1997 to $1.2 billion in 2005, according to the Disease Management Consortium, largely on the belief that DM programs cut medical costs and were therefore a good investment for private payers. Yet to date, no study has demonstrated conclusive medical cost savings from DM.

That doesn’t, however, mean that DM is a bad idea - especially for Medicare. 160,000 Medicare beneficiaries have been served by the Medical Health Support program, which provided chronic disease patients with periodic calls from nurses. The nurses give patients medical information, encourage them to seek treatment, remind them about their medical needs, and provide other forms of support.

The DM companies had financial incentives: Either achieve a 5% reduction in medical costs for their enrollees, net of service costs, or return their fees. When it became clear last year they weren’t going to make that goal, Medicare relaxed their requirements. Now, only a net savings is required in order for the vendors to keep their fees. It’s not clear if they’ll reach that goal, either. (The CMS pdf fact sheet politely describes the cost impact of these programs so far as “nominal.”)

It’s too early to draw definitive conclusions about this experiment, especially since the data are not yet publicly available. But here are some thoughts to consider:

• Cost savings may not be the appropriate goal for DM with a population of this kind. Convenience (especially for those with limited mobility or money) and health improvement outcomes are also worthwhile objectives. The program should be evaluated for these indicators, and not for cost alone.
• While the entire program may not be cost-effective, elements of it might be. Medicare should continue the experiment under modified conditions.
• There may be opportunities to reduce program costs and improve efficiencies while delivering similar results.

Senators from the home states of the companies involved, including John Kerry and Lamar Alexander, think the experiment should be continued. The Times implies they’re just providing a constituent service to home state employers, but they may in fact be right. There is more to be learned about the role of DM in Medicare, and in the overall health system.

Overall, the DM industry is likely to experience a shakeout in the next year or two - for both private and public payers. Assumptions about its cost-effectiveness are likely to be overturned. The most likely end result? A re-engineered DM concept, which differs from today’s both in design and in outcome measurements. Medicare can play a vital role in DM research, discovering which elements work, which need to be added, and which can be discarded.

Separate And Unequal: Healthcare in the United States

The nation commemorated the 40th anniversary of Martin Luther King’s death last week. Here’s a quote from him that didn’t get much play in the testimonials: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Two recent studies highlights the lack of progress we’ve made in four decades, and proposals from John McCain and the Florida State Senate show how little resonance Dr. King’s words have in some corners of public life.

Studies by the Robert Wood Johnson Foundation and the Harvard School of Public Health provide more documentation for something many Americans know from personal experience: The United States is a nation living under medical apartheid. The South Florida Times summarized the studies’ findings as follows:

“… elderly black and Hispanic patients often received substandard care for common but serious conditions like heart attacks, congestive heart failure and pneumonia. Researchers say their data suggests that the nation’s healthcare system is racially and ethnically segregated, not just for the elderly, but across the board.”

Lead researcher, Dr. Ashish K. Jha, said:

“When we see ongoing segregation in housing and education [in America,] it may not be surprising that we’re seeing very different administration of care in hospitals that serve blacks and Hispanics versus hospitals that mostly serve whites. But we’re not talking about [failures of] high tech medicine. This is basic stuff, like failing to administer aspirin or beta blockers to patients suffering a heart attack; treatments that we’ve known about for 20 years.’’

These studies are consistent with earlier findings that, at all levels of incomes, black Americans die years earlier than whites. The infant mortality rate for African American babies is 2.5 times greater than it is for non-Hispanic whites, according to data from the National Center for Health Statistics, giving us the worst infant mortality rate of any industrialized nation on Earth, except Latvia. It should be noted that these recent studies demonstrate that Hispanics in this country also experience extreme disparities in medical care.

Are you OK with that? Then how about this? Lack of health insurance results in the deaths of 18,000 Americans each year, according to studies compiled by the National Academies’ Institute of Medicine. That equates to 49 or 50 deaths every day.

How are politicians responded to this ongoing health crisis among “the least of us”? The Florida State Senate is proposing to cut $803 million in health care financing for the low-income residents, the poor, and senior citizens - a figure the Orlando Sentinel calls “staggering.” Disabled Floridians and recent transplant recipients would be among those losing medical coverage. “This is a death sentence for a lot of people,” said a bone-marrow transplant patient. He’s right.

For his part, according to the Boston Globe, John McCain is still “working out the details” of his health plan. He’s already done enough. Although some friendly reporters are emphasizing his willingness to offer tax credits, rather than just tax deductions (as his GOP predecessors have done), his plan is the same prescription for disaster that Bush’s and Giuliani’s have been. Like them, he proposes to end tax benefits for employers providing health insurance, which would effectively scrap the current employer-funded system.

McCain would replace the employer system with a tax benefit that would fall far short of covering the added costs of health insurance, especially since the bargaining clout of employers would be scrapped for a free-for-all system of individual buyers without expertise or buying power. The result would be a plan that creates substantially higher out-of-pocket costs for working Americans without extending insurance to those currently uncovered.

McCain attempts to make his plan more politically palatable than his predecessors’ by speaking in vague terms about “high risk pools” and subsidies. But, except for the inclusion of tax credits as well as deductions, he has yet to differentiate his proposal from theirs in any concrete way. His refusal to place any requirements on insurance companies, together with his abandonment of the employer-based insurance system, would create enormous financial hardship for working people who suffer from cancer and other pre-existing conditions.

What about the poor and unemployed? It’s true that some might benefit from a tax credit - but the $5,000-per-family figure McCain mentioned wouldn’t cover premiums for very many lower-income people. And they’re unlikely to be able to afford the difference between $5,000 and the actual cost of insurance, which would likely be thousands of dollars per year. The net result? Continued lack of coverage for those currently doing without medical care.

Obama and Clinton supporters are free to continue their blood feud over which has the better health plan. I’ve argued that Obama’s is more politically feasible and, in the end, more progressive. Some colleagues in the health policy world disagree. But we all agree that Sen. Clinton’s plan would also be a vast improvement over McCain’s. And the actions of the Florida State Senate are unconscionable.

To be clear, we’re talking about two distinct policy issues here - the problem of the uninsured, and the ethnic and racial divide in American healthcare. But these two issues are closely related, and both cut to the heart of what it means to be a just society in the 21st century.

Heated Debate Over Mandates

The intensity of debate around health care reform is reaching new heights, especially around mandates. They were a key part of the Massachusetts reform law and are central to the Clinton health proposal. Obama’s reform plan does not include a mandate provision, at least initially, although he indicated during the early debates that he would consider adding one later if voluntary programs don’t succeed in getting near-universal coverage.

Clinton has been hammering Obama over this issue for months, saying that her plan guarantees “universal coverage” and his doesn’t. Here’s the simple fact: Mandates do not create universal coverage. When the pundits were celebrating the “Massachusetts miracle” — including many of the same “health wonks” now touting the Clinton plan — I was one of the few to point out that the plan was actually more mirage than miracle. It kicked the unpleasant decisions down the road so that Mitt Romney and his Democratic and labor collaborators could take an undeserved victory lap at the signing ceremony.

Sure enough, the legal authority responsible for the Massachusetts plan eventually acknowledged that the plan will leave 20% of that state’s uninsured without coverage, and the real number may be higher. Why? Because there is a wide band of people who would suffer financial hardship if compelled to pay the premiums, and it’s financially infeasible to subsidize them all.

The Clinton plan, should it ever be passed, will suffer the same fate. I will happily bet Paul Krugman on that point. He should know better than to claim that the Clinton plan could provide universal coverage. Experience and political common sense say that just ain’t so.

That’s not to say there aren’t valid arguments in favor of mandates. There are, which is why they’re part of conventional health policy wisdom. Mandates solve the “selection problem,” where insurance costs become too high because only sicker people buy insurance voluntarily. They also allow funds that are now used to reimburse providers for treating the uninsured to be used in better ways. And I think the Obama team is over-optimistic about voluntary compliance levels.

Krugman and other supporters of the Clinton plan are now pointing to a study by the respected Urban Institute as a validation of their position. It’s a good study that shows mandates are the only way to achieve something like “universal coverage” — if you first exclude single-payer coverage from the mix. (They also exclude my preferred approach — core basic coverage paid from tax revenues, with the ability to “buy up” into private plans through a subsidy/voucher approach.)

Here’s one problem: The paper’s authors admit, albeit indirectly, that they overestimated the ability of Massachusetts to achieve universal coverage. They make the same mistake here. Here’s another: Sen. Clinton and the supporters of her plan have been evasive about how they would enforce this mandate, and enforcement is key to the Urban Institute’s findings. In a recent interview she was forced to acknowledge, for example, that she would consider garnishing wages. And while she has boasted about tying mandate obligations to personal income, she has been equally vague about what level of personal income she might allocate for healthcare.

Those provisions are political non-starters. Massachusetts is easy compared to the country as a whole — both in terms of political climate and the scope of the uninsured problem. Yet they had to leave 20% of the uninsured without coverage. That figure would equate to about 8 million people nationwide. If we accept Sen. Clinton’s figure of “15 million uninsured” under the Obama plan (and that figure was chosen by a journalist, not a technical study), that means a difference of seven million — in return for a plan that might actually get passed in Congress. (The gap could be filled in later, after premiums are brought under control and it becomes more politically feasible.)

And consider what mandates might do to a family of four. While Clinton won’t tell us the percentage of income she’d tie to mandates, many analysts have been using 10%. If premium assistance is provided up to 300% of the poverty level, a family of four trying to survive on $75,000 could be forced to pay $7,500 to insurance companies or in health copayments. The alternative could be tax penalties or garnished wages. That seems unfair. I also believe it’s a serious misread of American political culture to think that kind of mandate could ever get through Congress.

Krugman was outraged by an Obama ad that seemed to channel “Harry and Louise” from the 1994 anti-reform campaign. He says that mandates are to “prevent some people from gaming the system,” he writes, as if that family of four could write out that $7,500 check if not for some moral hazard. (Granted, there are “gamers,” but they tend to be the young, healthy, and relatively prosperous.)

We already have a mechanism for “shared responsibility,” and it’s called taxation. Adding 10% to struggling families’ financial burdens reads politically like a highly regressive tax to be paid to insurance companies - and the Wall Street Journal suggests that insurance companies do prefer the Clinton plan. That could create rough political waters in the general elections, especially for a Democrat.

While mandates have real value, political realities and issues of fairness suggests that the health reform process should start elsewhere. What’s even more clear is that they are not a mechanism for creating “universal coverage,” whatever the politicians say.

(extracted from a piece in the Huffington Post)

Health Information Online: New & Interesting Developments

People keep trying to provide comparative cost information that health “consumers” can use to make their treatment decisions. Many of us have predicted that someone would try to be the Travelocity of health purchasing, and Carol.com says it wants to be exactly that (as reported in the Minneapolis Star Tribune).

I tried the site. It’s ambitious, and in its own way it’s also overtly political. “Competition has changed every market but health care,” the Flash introduction says. “That’s about to change.” Some would argue that there are many reasons why health care can never fit simple market models, including confusion about what exactly is being bought and sold. (Is it “wellness”? A fix for your specific health problem? Or just a set of individual treatments, none of which can be predicted in advance?)

I had some difficulty following the process for acid reflux, the condition I’d selected as a test. It came up with only one “price” of $213, from one provider - but what was it for? Diagnosis? Treatment? End-to-end cure? How much will I need to pay for pharmaceuticals? Will I need to return quarterly? Annually? Ever? If it’s just one office visit, it should say so. If it’s a treatment plan, it should say that.

This is not to knock Carol.com’s creators unfairly. They have an interesting take on this often-discussed idea, and according to the Star Tribune they’ve already affected some unit pricing in the area. And I love their attempt to use decision trees to help people figure out what they need. (Try it - it’s interesting.)

But they need to be cautious about over-promising, and they need to recognize that most of their users will be insured - which will make their pricing information misleading, if not irrelevant. Most of all, they need to define the commodity that’s truly being bought and sold in the health market. That’s the hard part.

Meanwhile, Kaiser Permanente seems to be pioneering an different model for Internet interaction with the health process. iHealthBeat summarizes the features of Kaiser’s new member portal (free registration required), as originally reported in the Sacramento Business Journal. Features include appointment scheduling, prescription refills, viewing lab results, and e-mailing doctors (who will presumably write back).

A staff model HMO like Kaiser is the obvious place to develop a successful service of this kind. All the needed information is present under one roof. Since doctors are employees and not independent businesses, they can take time to answer emails without losing income.

The logical next step is to develop a similar service for the majority of Americans who don’t belong to group or staff model HMOs. That will require some leg work and some cooperation, especially among physicians, laboratories, and other diagnostic providers. And it will require financial incentives for providers to participate, including a payment schedule for answering emails and a system for transferring medical information securely.

(Carol.com, on the other hand, charges providers to participate. That may alter the blend of participants away from the lowest-cost providers, especially on the physician side. And who makes sure data is updated?)

What else will it take to succeed? A thorough knowledge of the inner workings of our so-called health “system,” and a clear-eyed look at the motivation of the participants.

In related news, California is posting a list of hospitals willing to provide discounts to uninsured patients, along with a comparison-shopping tool. Two Michigan health systems are posting their prices for common procedures (but note - these are charges, not the payments they typically receive for these services. Caveat emptor and all that.)

Prediction: Not very many people will use these California or Michigan portals. There will be one or more sites that do become popular someday, but they’ll look like a cross between Carol.com, secure email, and a supercharged search engine.

The goal is to create the classic “knowledge pyramid”: Data needs to be organized into information, and information needs to be organized to become knowledge. If somebody builds it, they will come.

Global Warming And Individual Health

Add the fight against global warming to the list of political battles that impact the health arena.  A long-term study of global warming’s impact on medical needs was conducted by Australian researchers in order to help that country’s single-payer system plan for the future.

According to the Sydney Morning Herald, researchers found that  “heat waves - defined as a periods of three days or more in which the average temperature exceeded 35 degrees - produced a seven per cent increase in admissions to hospital and a four per cent increase in ambulance trips.”  The Herald adds that “the number of people admitted for kidney disease increased by 17 per cent (during heat waves), and the number admitted for mental illness increased by seven per cent.”

Melbourne’s Herald Sun (ironic name, that) quotes the study’s lead researcher, Prof. Kevin Parton, as saying that mosquito-borne diseases will also be on the upswing as the result of warming trends.

There are those who will say these reports are “alarmist,” of course, although they rely of widely accepted climatological and medical research.  The study is, unfortunately, not alarmist.   On the upside, the long-term investment opportunities look good for related medical products - including antibiotics, antidepressants, dialysis technology, and bug repellent.

I wish I were kidding.