originally appeared in USA Today from the Detroit Free Press:
At Providence Park Hospital in Novi, Mich., the artwork hanging on the walls isn't covered with glass, in an effort to absorb noise.
Special air-blowing vests keep patients warm pre-surgery. Private rooms are the norm. Staffers regularly check in with patients to anticipate their toilet and showering needs to cut down on call-light usage. Patients are given clear discharge instructions. Cleaning is no longer done at night. Patients are taught the difference between "pain-free" and "pain-controlled."
The reason for these changes at Providence Park and similar ones at other hospitals across the country is to ensure high scores on patient satisfaction surveys, the results of which will affect Medicare reimbursement rates, starting next year.
At issue are millions of dollars annually, all the more significant as the industry sees so many other dollars slipping away. In fiscal year 2013, for example, the pot is $964 million, according to the federal government's Centers for Medicare & Medicaid Services.
Amenities such as free lattes and valet parking are not new to hospitals. They began offering them years ago in a high-stakes fight to lure patients. However, what hospitals are doing now is, for the most part, tailored to the survey questions they know patients will be asked.
Noise is a big topic. Providence Park has reduced the number of loud carts pushed along its corridors. Instead, patients get "quiet kits" containing ear plugs and relaxation-inducing lavender lotion.
Another survey topic is staff attention.
Bells and whistles make it a nicer environment for patents, but if you're not addressing holistic, spiritual care, they're not going to rate it well, according to St. John Providence Health System's chief quality officer. We take these things and focus it up from there in addressing the patients' needs.
The Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS (pronounced H-caps) — first instituted in 2006 as a 27-question survey for discharged patients — was initially designed to be a comparison tool people could use to choose a hospital. Under the Affordable Care Act, it morphed into a dollars-loaded query in October, the start of the 2013 fiscal year.
In January, another five questions will be added.
Hospitals are at risk of losing 1% of their payouts this year if they don't do well on the surveys. That will jump to 2% by fiscal year 2017.
They have to submit a minimum of 100 surveys. To prevent them from cherry-picking the most favorable replies, the Centers for Medicare & Medicaid Services will do quarterly random audits of data.
In the past, hospitals and other providers were paid almost solely based on how much work they did — not on how well they did for patients, the Centers for Medicare & Medicaid Services said in an e-mail. Since the ACA, however, we have a number of programs in place ... that reward hospitals and doctors based on the quality of care they deliver for patients.
Among the topics in the surveys are:
• Nursing and doctor care (Did they treat you with courtesy and respect and explain things to you clearly?).
• The hospital environment (Was your room clean and quiet).
• Pain (Was your pain well-controlled).
• The discharge process.
At Botsford Hospital, changes include nurses talking to patients hourly to inquire if they need to use the bathroom and to ensure all personal items such as water, the call button and the phone are within arm's reach; audio-video relaxation system in patient rooms, and detailed "Passport to Care" discharge packets.
It's important to score that well, because that reflects we're doing the right thing for our patients, according to Botsford's director of nursing services. We're not doing it just for the money. We're doing it because it's the right thing to do.
But others in southeastern Michigan, like St. Joseph Mercy and Beaumont health systems and Sinai-Grace Hospital, said they aren't motivated by the Medicare payments to improve patient care.
We don't frankly respond to changes in reimbursement or other national surveys and comparisons, said Beaumont's executive vice president of operations. We've been working for decades to improve patient satisfaction.
He said that less than $3 million is at stake, a tiny portion of the hospital's $2.2 billion operation.
A University of Michigan associate professor of pharmacy and public health who has researched patient satisfaction surveys, said this regulatory move is a positive one, citing among other reasons the importance of patient empowerment.
The problem is America is a free-market economy, he said. We need to give patients a way to speak on what they think about health care, what works for them, how health care professionals work for them, because those factors go into determining whether treatments are successful.
26 December 2012
23 December 2012
Obamacare, And The Government's Cruel War On Innovation
originally appeared in Forbes:
As a young professor at Johns Hopkins I was around at the beginning of the academic study of health care costs. Over time it became clear that research support in the field was going to be circumscribed by a powerful and largely unspoken common objective. Foundations and federal research agencies were committed to the view that central control of payment would lead to lower costs and make the expansion of coverage possible.
Simply, national health insurance was the obvious objective, a view commonly but simplistically justified by reference to other “industrialized,” or “advanced,” or, “civilized,” countries. “Single payer” coverage evolved as the strategy to take the U.S. in this direction. The majority of research grants and demonstration programs were meant to show how government payment would produce more efficient and clinically effective care. Researchers would construct the path that would force the U.S. healthcare system to get right with history. The cost of this intellectual hegemony has been that Congress has had very little to draw on by way of credible alternatives to improving our system. The alternative case is hardly more than descriptions of the failures of the Canadian and British systems.
The inevitability of a national healthcare system has shaped the way Congress has attempted to regulate hospitals and doctors ever since the passage of Medicare and Medicaid in 1965. Two interrelated themes characterize all federal policy related to controlling costs ever since; namely, central planning and resisting technological innovation.
In 1974, the government set up a planning apparatus, advanced as a means to curtail health care cost inflation. One of its central aims was to constrain the development and application of new technology. Early on the government had determined that technology was the single most important factor in rising health care costs. This view was confirmed by European nationalized systems that worked hard to resist the proliferation of new technologies. The government’s first outing in planning under the 1974 statute was to retard the proliferation of the newly developed magnetic resonance imaging technology that subsequently proved to be the most powerful diagnostic tool since the introduction of x-rays, and the coming of today’s use of sophisticated genetic testing.
While medical technology has survived, largely on its ability to demonstrably improve clinical outcomes, its dispersion has been limited both in scope and scale by the federal government. Federal regulation of new drugs and devices has expanded hugely over the last thirty years. Indeed, many innovators and entrepreneurs never start new companies based on a promising new technology because they presume that ultimately the government will deny their ability to enter the market, or the process will be so long that their new company will never survive the wait. Through device regulation government has undeniably “chilled” innovation in health care.
Interestingly, government planning has distorted the use of the technology that does emerge as well. By concentrating new technology in hospitals where federal regulation could reach more readily than it could into doctors’ practices, hospitals play home to the most expensive technologies, such as the new proton beam therapy. With their greater ability to assume debt to pay for machines that may cost as much as a $500 million, our system encourages hospitals to buy the most costly technology, useful in a tiny number of cases. They often compete over who has the newest dramatic technology.
Meanwhile, older, less costly but more profitable technology escapes with government’s encouragement, to private outpatient settings. For example, same-day surgery for a wide variety of maladies is now performed in the mini-hospitals that many specialists’ offices have become. The result is decisionmaking by individual doctors relating to procedures from which they profit. The discipline once provided by hospital practice is gone; America is likely getting too much surgery as a result.
Not surprisingly Obamacare continues government’s dyspeptic attitude toward technological innovation. Next year the federal government is set to impose a 2.3 percent surtax on the sales of all medical technology. This move alone is a clear signal of the hostility that the government can send to a specific industry. But, the legislation proposes another aspect even less congenial to new drugs and technologies: Various government agencies are now empowered to establish a new threshold for judging products beyond the safety standards now in place. Clinical efficacy, judged using economic cost data, will have to be proved before new drugs and medical devices are approved. As I noted in my Fogarty Lecture at Stanford, this standard alone will greatly depress new innovation. A government that seeks to encourage innovation does not create multiple means to frustrate its champions.
But, Obamacare does encourage one innovation, if a concept well over three decades old can be called new. As part of a general strategy to control costs (and, it is argued, improve care) the government is mandating a new federal platform for “electronic” medical records. (The very language makes apparent just how old the technology is.). The idea is that an orthopedist in Aspen fixing a skier’s broken leg would benefit from knowing of her patient’s tonsillectomy in Buffalo twenty years before. Research suggests that electronic records are unlikely to save money or improve care in all but exceptional settings, such as the Mayo Clinic where all of one’s doctors practice in the same location. In the end, government would have access to and supervise the retrieval of everybody’s medical information. Maybe we can be trained that if we must break a leg, it would be best to do so on a weekday between 9 and 4 Washington time.
Obamacare reveals once again that our government seems incapable of seeing our economy as an integrated whole. Healthcare has been second only to design of chips and software as the most fecund area of innovation in the U.S. for many years. Tens of thousands of companies, millions of jobs, and many of the most incredible ideas that have translated into longer and more productive lives come from this sector. To think of purposively making it drink from the “shrink me” bottle has implications for the whole economy.
Recently when asked about layoffs in the health technology industry a government official said that Obamacare’s expansion of coverage should induce increased demand for care that will more than make up for the $20 billion in new taxes the industry will pay every year. Sounds like gravity-free economics. Thousands of years of trading have led businesspersons never to buy the proposition that losses can be made up by selling more, the more so when those loses are imposed by a government that has shown that it thinks what you make isn’t necessary.
As a young professor at Johns Hopkins I was around at the beginning of the academic study of health care costs. Over time it became clear that research support in the field was going to be circumscribed by a powerful and largely unspoken common objective. Foundations and federal research agencies were committed to the view that central control of payment would lead to lower costs and make the expansion of coverage possible.
Simply, national health insurance was the obvious objective, a view commonly but simplistically justified by reference to other “industrialized,” or “advanced,” or, “civilized,” countries. “Single payer” coverage evolved as the strategy to take the U.S. in this direction. The majority of research grants and demonstration programs were meant to show how government payment would produce more efficient and clinically effective care. Researchers would construct the path that would force the U.S. healthcare system to get right with history. The cost of this intellectual hegemony has been that Congress has had very little to draw on by way of credible alternatives to improving our system. The alternative case is hardly more than descriptions of the failures of the Canadian and British systems.
The inevitability of a national healthcare system has shaped the way Congress has attempted to regulate hospitals and doctors ever since the passage of Medicare and Medicaid in 1965. Two interrelated themes characterize all federal policy related to controlling costs ever since; namely, central planning and resisting technological innovation.
In 1974, the government set up a planning apparatus, advanced as a means to curtail health care cost inflation. One of its central aims was to constrain the development and application of new technology. Early on the government had determined that technology was the single most important factor in rising health care costs. This view was confirmed by European nationalized systems that worked hard to resist the proliferation of new technologies. The government’s first outing in planning under the 1974 statute was to retard the proliferation of the newly developed magnetic resonance imaging technology that subsequently proved to be the most powerful diagnostic tool since the introduction of x-rays, and the coming of today’s use of sophisticated genetic testing.
While medical technology has survived, largely on its ability to demonstrably improve clinical outcomes, its dispersion has been limited both in scope and scale by the federal government. Federal regulation of new drugs and devices has expanded hugely over the last thirty years. Indeed, many innovators and entrepreneurs never start new companies based on a promising new technology because they presume that ultimately the government will deny their ability to enter the market, or the process will be so long that their new company will never survive the wait. Through device regulation government has undeniably “chilled” innovation in health care.
Interestingly, government planning has distorted the use of the technology that does emerge as well. By concentrating new technology in hospitals where federal regulation could reach more readily than it could into doctors’ practices, hospitals play home to the most expensive technologies, such as the new proton beam therapy. With their greater ability to assume debt to pay for machines that may cost as much as a $500 million, our system encourages hospitals to buy the most costly technology, useful in a tiny number of cases. They often compete over who has the newest dramatic technology.
Meanwhile, older, less costly but more profitable technology escapes with government’s encouragement, to private outpatient settings. For example, same-day surgery for a wide variety of maladies is now performed in the mini-hospitals that many specialists’ offices have become. The result is decisionmaking by individual doctors relating to procedures from which they profit. The discipline once provided by hospital practice is gone; America is likely getting too much surgery as a result.
Not surprisingly Obamacare continues government’s dyspeptic attitude toward technological innovation. Next year the federal government is set to impose a 2.3 percent surtax on the sales of all medical technology. This move alone is a clear signal of the hostility that the government can send to a specific industry. But, the legislation proposes another aspect even less congenial to new drugs and technologies: Various government agencies are now empowered to establish a new threshold for judging products beyond the safety standards now in place. Clinical efficacy, judged using economic cost data, will have to be proved before new drugs and medical devices are approved. As I noted in my Fogarty Lecture at Stanford, this standard alone will greatly depress new innovation. A government that seeks to encourage innovation does not create multiple means to frustrate its champions.
But, Obamacare does encourage one innovation, if a concept well over three decades old can be called new. As part of a general strategy to control costs (and, it is argued, improve care) the government is mandating a new federal platform for “electronic” medical records. (The very language makes apparent just how old the technology is.). The idea is that an orthopedist in Aspen fixing a skier’s broken leg would benefit from knowing of her patient’s tonsillectomy in Buffalo twenty years before. Research suggests that electronic records are unlikely to save money or improve care in all but exceptional settings, such as the Mayo Clinic where all of one’s doctors practice in the same location. In the end, government would have access to and supervise the retrieval of everybody’s medical information. Maybe we can be trained that if we must break a leg, it would be best to do so on a weekday between 9 and 4 Washington time.
Obamacare reveals once again that our government seems incapable of seeing our economy as an integrated whole. Healthcare has been second only to design of chips and software as the most fecund area of innovation in the U.S. for many years. Tens of thousands of companies, millions of jobs, and many of the most incredible ideas that have translated into longer and more productive lives come from this sector. To think of purposively making it drink from the “shrink me” bottle has implications for the whole economy.
Recently when asked about layoffs in the health technology industry a government official said that Obamacare’s expansion of coverage should induce increased demand for care that will more than make up for the $20 billion in new taxes the industry will pay every year. Sounds like gravity-free economics. Thousands of years of trading have led businesspersons never to buy the proposition that losses can be made up by selling more, the more so when those loses are imposed by a government that has shown that it thinks what you make isn’t necessary.
17 December 2012
Hospital Systems Branch Out as Insurers
originally appeared in The Wall Street Journal:
A increasing number of hospital systems are moving to start their own insurance plans, aiming to broaden their roles and prepare for the changes coming under the federal health-care overhaul.
Piedmont Healthcare and WellStar Health System, both in the Atlanta area, are set to announce a jointly owned insurance arm, with the goal of marketing coverage to employers and Medicare recipients in 2014. They also will consider selling coverage on a health exchange, one of the online insurance marketplaces required in each state by the health-overhaul law.
Piedmont and WellStar said their health plan would be built largely around their 10 hospitals and hundreds of affiliated doctors, and they will offer a competitive premium. We're broadening the reach of our delivery system, according to Piedmont's interim chief operating officer, who added that he expects the strategy to clearly have a positive impact on the quality of care.
In recent months, northern California's Sutter Health and New York's North Shore-Long Island Jewish Health System have said they would start selling health plans. A 2011 survey of 100 hospital leaders by health research firm Advisory Board Co. found that 20% of them intended to market an insurance plan. In 2010, around 10% of community hospitals owned, or were part of systems that owned, health plans, according to the American Hospital Association.
Typically, the new entrants will offer health-maintenance-organization-style plans that allow patients limited access to doctors and hospitals outside their network.
Some systems that have had limited insurance operations are expanding, including MedStar Health in the Baltimore-Washington area, which will add Medicare plans next year and is likely to have a plan on the Maryland health exchange, and Indiana University Health, which expects to start offering health plans to employers in 2013.
The moves reflect a broader blurring of the lines between those who provide health care and those who pay for it, as both sides increasingly aim to provide more efficient, seamless care. The hospital systems themselves are the product of a consolidation that brought together many hospitals and doctors.
Driving the trend is the mounting pressure to reduce costs, as well as the changes set to be unleashed by the health-care overhaul. In addition to adding coverage for millions of people, partly by expanding Medicaid, the federal-state health program for low-income Americans, the law will cut back on hospital payments by Medicare, the federal insurance program for the elderly. Some hospitals are starting their own plans for Medicaid recipients.
The hospitals expect to get a shrinking slice of reimbursements from the fees insurers and others pay for specific services. That payment system has been blamed for fueling rising health costs. Providers who depend solely on fee-for-service revenue will eventually have a slow death, according to the chief executive of North Shore-Long Island Jewish.
He said his hospital system intended to offer its own exchange plan, perhaps in 2014, the first year the health exchanges are supposed to be running. I want to go upstream as much as possible and take the premium dollar at the source, he said.
Because insurers pay claims for all doctor visits, lab tests and other care, they get a full view of their members. Hospital systems say they need direct access to that data, which they can get by offering their own plans, to manage patients better, avoiding duplication and detecting and treating problems early to head off pricey procedures later.
It's so much better for us to have, at least for a slice of our business, a total picture as to what's going on, according to a senior vice president at Sutter Health.
Still, most hospital systems have been stopping short of getting an insurance license, often taking more limited steps like striking reimbursement deals with insurers that reward them for providing more efficient care. Some are also forging partnerships with insurers that sometimes involve jointly selling a health plan built around the system.
Some hospital operators, including the University of Pittsburgh Medical Center and Intermountain Healthcare in Utah, long have had health plans. Others, including some health systems considering them now, have tried and failed with them in the past. The failures in part reflect the difficulties of reconciling conflicting interests: Hospitals typically make money when they fill their beds with patients, and health plans pay the bills for those admissions.
Another factor: Patients revolted against HMOs in the 1990s, when they were popular with employers, because they felt that HMOs limited their choices of providers and access to care.
The hospital systems may also create new fault lines as they compete against the other insurance companies that pay them, though their size and market power will make it tough for insurers to shut them out.
Aetna Inc.'s partnerships are lower cost, more flexible and more scalable for systems than building health plans from scratch, according to the chief executive of Aetna's Accountable Care Solutions business. Aetna's network includes providers who operate their own networks, but if a system became a significant competitor, competitive dynamics might push us…in a direction where we might not want to contract with them in a preferred state, or favor the system in Aetna's own plan designs.
Many of [the hospital systems] are also folks we do business with, according to Blue Shield of California's senior vice president for network management. There's a potential for that to be difficult.
Like insurers, which are building lower-cost narrow network plans for the exchanges, the hospital systems are betting that consumers will be willing to accept a smaller choice of health-care providers in return for the promise of smoothly integrated care and premiums that are likely to be lower. The hospital systems plan to build their coverage around their own networks, but may fill them out with other providers as well.
Hospital systems say their focus is on providing high-quality care, and they think that the better technology that helps them closely track patients will ensure they avoid some of the financial pitfalls of decades ago. Also, today there is financial urgency, according to the chief executive of Evolent Health, which is advising many hospital systems pursuing integrated operations, including Piedmont.
Piedmont and WellStar together have about 30% of the inpatient market share in the Atlanta area. Working together will spread out the fixed costs of starting a health plan, as well as offer greater reach in the combined network, according to the chief executive of WellStar.
A increasing number of hospital systems are moving to start their own insurance plans, aiming to broaden their roles and prepare for the changes coming under the federal health-care overhaul.
Piedmont Healthcare and WellStar Health System, both in the Atlanta area, are set to announce a jointly owned insurance arm, with the goal of marketing coverage to employers and Medicare recipients in 2014. They also will consider selling coverage on a health exchange, one of the online insurance marketplaces required in each state by the health-overhaul law.
Piedmont and WellStar said their health plan would be built largely around their 10 hospitals and hundreds of affiliated doctors, and they will offer a competitive premium. We're broadening the reach of our delivery system, according to Piedmont's interim chief operating officer, who added that he expects the strategy to clearly have a positive impact on the quality of care.
In recent months, northern California's Sutter Health and New York's North Shore-Long Island Jewish Health System have said they would start selling health plans. A 2011 survey of 100 hospital leaders by health research firm Advisory Board Co. found that 20% of them intended to market an insurance plan. In 2010, around 10% of community hospitals owned, or were part of systems that owned, health plans, according to the American Hospital Association.
Typically, the new entrants will offer health-maintenance-organization-style plans that allow patients limited access to doctors and hospitals outside their network.
Some systems that have had limited insurance operations are expanding, including MedStar Health in the Baltimore-Washington area, which will add Medicare plans next year and is likely to have a plan on the Maryland health exchange, and Indiana University Health, which expects to start offering health plans to employers in 2013.
The moves reflect a broader blurring of the lines between those who provide health care and those who pay for it, as both sides increasingly aim to provide more efficient, seamless care. The hospital systems themselves are the product of a consolidation that brought together many hospitals and doctors.
Driving the trend is the mounting pressure to reduce costs, as well as the changes set to be unleashed by the health-care overhaul. In addition to adding coverage for millions of people, partly by expanding Medicaid, the federal-state health program for low-income Americans, the law will cut back on hospital payments by Medicare, the federal insurance program for the elderly. Some hospitals are starting their own plans for Medicaid recipients.
The hospitals expect to get a shrinking slice of reimbursements from the fees insurers and others pay for specific services. That payment system has been blamed for fueling rising health costs. Providers who depend solely on fee-for-service revenue will eventually have a slow death, according to the chief executive of North Shore-Long Island Jewish.
He said his hospital system intended to offer its own exchange plan, perhaps in 2014, the first year the health exchanges are supposed to be running. I want to go upstream as much as possible and take the premium dollar at the source, he said.
Because insurers pay claims for all doctor visits, lab tests and other care, they get a full view of their members. Hospital systems say they need direct access to that data, which they can get by offering their own plans, to manage patients better, avoiding duplication and detecting and treating problems early to head off pricey procedures later.
It's so much better for us to have, at least for a slice of our business, a total picture as to what's going on, according to a senior vice president at Sutter Health.
Still, most hospital systems have been stopping short of getting an insurance license, often taking more limited steps like striking reimbursement deals with insurers that reward them for providing more efficient care. Some are also forging partnerships with insurers that sometimes involve jointly selling a health plan built around the system.
Some hospital operators, including the University of Pittsburgh Medical Center and Intermountain Healthcare in Utah, long have had health plans. Others, including some health systems considering them now, have tried and failed with them in the past. The failures in part reflect the difficulties of reconciling conflicting interests: Hospitals typically make money when they fill their beds with patients, and health plans pay the bills for those admissions.
Another factor: Patients revolted against HMOs in the 1990s, when they were popular with employers, because they felt that HMOs limited their choices of providers and access to care.
The hospital systems may also create new fault lines as they compete against the other insurance companies that pay them, though their size and market power will make it tough for insurers to shut them out.
Aetna Inc.'s partnerships are lower cost, more flexible and more scalable for systems than building health plans from scratch, according to the chief executive of Aetna's Accountable Care Solutions business. Aetna's network includes providers who operate their own networks, but if a system became a significant competitor, competitive dynamics might push us…in a direction where we might not want to contract with them in a preferred state, or favor the system in Aetna's own plan designs.
Many of [the hospital systems] are also folks we do business with, according to Blue Shield of California's senior vice president for network management. There's a potential for that to be difficult.
Like insurers, which are building lower-cost narrow network plans for the exchanges, the hospital systems are betting that consumers will be willing to accept a smaller choice of health-care providers in return for the promise of smoothly integrated care and premiums that are likely to be lower. The hospital systems plan to build their coverage around their own networks, but may fill them out with other providers as well.
Hospital systems say their focus is on providing high-quality care, and they think that the better technology that helps them closely track patients will ensure they avoid some of the financial pitfalls of decades ago. Also, today there is financial urgency, according to the chief executive of Evolent Health, which is advising many hospital systems pursuing integrated operations, including Piedmont.
Piedmont and WellStar together have about 30% of the inpatient market share in the Atlanta area. Working together will spread out the fixed costs of starting a health plan, as well as offer greater reach in the combined network, according to the chief executive of WellStar.
Foreseeing the Issues in Medicare's Future
originally appeared in The New York Times:
The projected growth of Medicare costs is the single biggest contributor to the country’s long-term budget deficits, many estimates show. No cohort of Americans, with the possible exception of the very affluent, pays enough in Medicare taxes and premiums to cover its eventual Medicare costs.
Much of the early public discussion of the fiscal deadline has focused on taxes, and the decline of tax rates in recent decades has played a crucial role in creating the deficit. But the question of how to reduce the growth of Medicare costs will become increasingly important as the population continues to age and health costs continue to increase.
In the current fiscal talks, Republicans are pushing for significant changes to Medicare, in exchange for agreeing to tax increases. Democrats are arguing that Medicare is not the most pressing budget problem.
What follows is a primer on Medicare costs.
Q. Is Medicare really a bigger long-term problem than Social Security or military spending?
A. Yes. Over the next 25 years, the Congressional Budget Office projects that Medicare spending will rise to 6.7 percent of the gross domestic product, from 3.7 percent this year. (Other federal health care spending — like Medicaid, the insurance program principally for low-income families — is projected to rise to 3.7 percent of the G.D.P. in 2037, from 1.7 percent this year.)
In total, health care spending’s percentage of the G.D.P. is expected to rise by five points. Social Security spending is projected to rise by only 1.2 percentage points, to 6.2 percent in 2037. All other federal spending is expected to shrink by two percentage points, to 9.6 percent.
These estimates assume that some current policies continue, rather than that the various tax increases and spending cuts scheduled to take effect on Jan. 1 occur and remain in place.
Q. Why is Medicare the big problem?
A. As much attention as the aging of society receives, the rise of medical costs is a bigger budgetary problem. The faster growth of Medicare costs, relative to Social Security costs, highlights this difference.
Social Security costs will indeed grow in coming years, adding to the government’s fiscal problems. But those costs will not grow nearly as rapidly as Medicare’s, because Medicare costs are a function of both the aging society and the cost of treating any one person. Social Security’s costs stem almost entirely from the number of elderly people.
Q. Don’t most Americans pay for their Medicare benefits, through payroll taxes over their working lives?
A. No, and it is not even close. Two married 66-year-olds with roughly average earnings over their lives will end up paying about $122,000 in dedicated Medicare taxes through the payroll tax, including the part their employers pay, according to the Urban Institute. That married couple can expect to receive about three times as much — $387,000, adjusted for inflation — in benefits. The projected gap is even larger for younger people because of growing health care costs.
In short, the single biggest cause of the long-term deficit is that most people receive much more from Medicare than they give to it.
Q. Why are health costs growing so rapidly?
A. For a good reason and a bad one.
The good reason is that our medical system has made enormous progress in recent decades and can treat conditions that once would have killed people. Cancer treatment and cardiac care are two examples of areas with beneficial new treatments that are often not cheap. An American who turns 65 today can expect to live almost 20 more years on average, up from about 16 years in 1980.
The bad reason is that our health care system wastes large amounts of money. The United States spends roughly twice as much money per person on health care as many other rich countries, without getting vastly better results. Americans receive better care in some areas (some cancers) and worse in others (higher error rates).
It is hard to make the case that the American health system provides a good return on the money it spends. Life expectancy is higher and has grown over the last 30 years in Australia, Britain, Canada, France, Germany and Japan, among other countries.
Q. What are the possible solutions?
A. For starters, we could pay more in taxes. Tax revenues are near a 60-year low as a share of the G.D.P. They will rise somewhat as the economy recovers and incomes increase, but not by nearly enough to pay for growing health care costs.
Covering the future costs of Medicare and Medicaid solely through higher taxes would involve sharp increases — much greater than anything being debated now. So most budget experts believe that changes to Medicare need to be part of the deficit solution.
Among the options are raising the eligibility age, which is now 65; reducing benefits for affluent families; introducing more competition; and paying for quality of care, rather than quantity.
Q. What are the upsides and downsides of each?
A. Let’s take the options one at a time:
The main arguments for raising the eligibility age are that Americans live longer than they used to and that the 2010 health care law makes it easier for people to get insurance if they do not receive it from an employer. The main counterargument is that the longevity increase has been smallest for low-income people, who are most likely to benefit from Medicare coverage.
Reducing benefits for high-income families has some bipartisan support, given the recent increases in income inequality. But some Democrats worry that it could eventually undermine Medicare’s popularity, making it more akin to a welfare program.
Many Republicans advocate for more competition in health care, noting that competition has reduced prices and raised the quality of service in many industries. It has an uneven record of doing so in health care, though, in part because insurers can often profit by denying care.
Paying for quality rather than quantity has support from many economists. But it is not always easy. Patients and doctors often want to proceed with high-cost care even when research has not shown it to be effective.
Q. Does Medicare need to be fixed before Jan. 1?
A. Obviously not. Many potential changes would need to be phased in and would not bring savings for years. Other policy changes, like tax increases, can have a quicker effect on the deficit.
On the other hand, fixing Medicare is never going to be easy. Every budget negotiation between Congress and the president is an opportunity for them to make progress on a fiscal problem that is growing every year.
The projected growth of Medicare costs is the single biggest contributor to the country’s long-term budget deficits, many estimates show. No cohort of Americans, with the possible exception of the very affluent, pays enough in Medicare taxes and premiums to cover its eventual Medicare costs.
Much of the early public discussion of the fiscal deadline has focused on taxes, and the decline of tax rates in recent decades has played a crucial role in creating the deficit. But the question of how to reduce the growth of Medicare costs will become increasingly important as the population continues to age and health costs continue to increase.
In the current fiscal talks, Republicans are pushing for significant changes to Medicare, in exchange for agreeing to tax increases. Democrats are arguing that Medicare is not the most pressing budget problem.
What follows is a primer on Medicare costs.
Q. Is Medicare really a bigger long-term problem than Social Security or military spending?
A. Yes. Over the next 25 years, the Congressional Budget Office projects that Medicare spending will rise to 6.7 percent of the gross domestic product, from 3.7 percent this year. (Other federal health care spending — like Medicaid, the insurance program principally for low-income families — is projected to rise to 3.7 percent of the G.D.P. in 2037, from 1.7 percent this year.)
In total, health care spending’s percentage of the G.D.P. is expected to rise by five points. Social Security spending is projected to rise by only 1.2 percentage points, to 6.2 percent in 2037. All other federal spending is expected to shrink by two percentage points, to 9.6 percent.
These estimates assume that some current policies continue, rather than that the various tax increases and spending cuts scheduled to take effect on Jan. 1 occur and remain in place.
Q. Why is Medicare the big problem?
A. As much attention as the aging of society receives, the rise of medical costs is a bigger budgetary problem. The faster growth of Medicare costs, relative to Social Security costs, highlights this difference.
Social Security costs will indeed grow in coming years, adding to the government’s fiscal problems. But those costs will not grow nearly as rapidly as Medicare’s, because Medicare costs are a function of both the aging society and the cost of treating any one person. Social Security’s costs stem almost entirely from the number of elderly people.
Q. Don’t most Americans pay for their Medicare benefits, through payroll taxes over their working lives?
A. No, and it is not even close. Two married 66-year-olds with roughly average earnings over their lives will end up paying about $122,000 in dedicated Medicare taxes through the payroll tax, including the part their employers pay, according to the Urban Institute. That married couple can expect to receive about three times as much — $387,000, adjusted for inflation — in benefits. The projected gap is even larger for younger people because of growing health care costs.
In short, the single biggest cause of the long-term deficit is that most people receive much more from Medicare than they give to it.
Q. Why are health costs growing so rapidly?
A. For a good reason and a bad one.
The good reason is that our medical system has made enormous progress in recent decades and can treat conditions that once would have killed people. Cancer treatment and cardiac care are two examples of areas with beneficial new treatments that are often not cheap. An American who turns 65 today can expect to live almost 20 more years on average, up from about 16 years in 1980.
The bad reason is that our health care system wastes large amounts of money. The United States spends roughly twice as much money per person on health care as many other rich countries, without getting vastly better results. Americans receive better care in some areas (some cancers) and worse in others (higher error rates).
It is hard to make the case that the American health system provides a good return on the money it spends. Life expectancy is higher and has grown over the last 30 years in Australia, Britain, Canada, France, Germany and Japan, among other countries.
Q. What are the possible solutions?
A. For starters, we could pay more in taxes. Tax revenues are near a 60-year low as a share of the G.D.P. They will rise somewhat as the economy recovers and incomes increase, but not by nearly enough to pay for growing health care costs.
Covering the future costs of Medicare and Medicaid solely through higher taxes would involve sharp increases — much greater than anything being debated now. So most budget experts believe that changes to Medicare need to be part of the deficit solution.
Among the options are raising the eligibility age, which is now 65; reducing benefits for affluent families; introducing more competition; and paying for quality of care, rather than quantity.
Q. What are the upsides and downsides of each?
A. Let’s take the options one at a time:
The main arguments for raising the eligibility age are that Americans live longer than they used to and that the 2010 health care law makes it easier for people to get insurance if they do not receive it from an employer. The main counterargument is that the longevity increase has been smallest for low-income people, who are most likely to benefit from Medicare coverage.
Reducing benefits for high-income families has some bipartisan support, given the recent increases in income inequality. But some Democrats worry that it could eventually undermine Medicare’s popularity, making it more akin to a welfare program.
Many Republicans advocate for more competition in health care, noting that competition has reduced prices and raised the quality of service in many industries. It has an uneven record of doing so in health care, though, in part because insurers can often profit by denying care.
Paying for quality rather than quantity has support from many economists. But it is not always easy. Patients and doctors often want to proceed with high-cost care even when research has not shown it to be effective.
Q. Does Medicare need to be fixed before Jan. 1?
A. Obviously not. Many potential changes would need to be phased in and would not bring savings for years. Other policy changes, like tax increases, can have a quicker effect on the deficit.
On the other hand, fixing Medicare is never going to be easy. Every budget negotiation between Congress and the president is an opportunity for them to make progress on a fiscal problem that is growing every year.
13 December 2012
Study: Holiday suicide myth persists
originally appeared in USA Today:
Suicides spiking during the holidays is a myth that comes back to haunt us every year.
The months of November, December and January actually have the lowest number of suicides per day, according to the University of Pennsylvania's Annenberg Public Policy Center, which analyzed 1999-2010 data from the Centers for Disease Control and Prevention (CDC). It found that averages were highest in the spring and summer.
There is still this sort of ironic thought that maybe there are people not happy at this time, according to the Public Policy Center. Songs and movies focused on the "holiday blues" -- including the perennial favorite It's a Wonderful Life -- also perpetuate the myth.
The center, which has tracked the media's reporting of suicides since 2000, looked at stories that linked suicides and the holidays. In 1999, 77% of those stories said, erroneously, that suicides increased over the holidays. The proportion of stories that supported that myth dropped after the center's analysis came out, but rose again last year to 76%.
The Public Policy Center tells us the return of the holiday-suicide connection may be related to the fact that the adult (ages 25 and older) suicide rate has increased in recent years in step with the Great Recession. With more people affected by suicide, news stories about suicide may be more common over the holidays, bringing the myth back to our attention.
In 2010, there were 38,364 suicides in the USA, an average of 105 a day. The month with the highest daily average in 2010 was July, with 111.3. The lowest, 98.2, was December. The CDC says suicide was the 10th leading cause of death in 2010.
Suicide-prevention experts say stories perpetuating the myth are not only wrong but dangerous.
The National Action Alliance for Suicide Prevention says that it's normal for people in their situation to end their life may be just that little nudge that puts them over.
They say anyone contemplating suicide should call the National Suicide Prevention Lifeline at 800-273-8255. Those who know someone in distress can call as well.
Media coverage needs to be more balanced. Coverage should include ways to prevent suicide, such as recognizing warning signs, as well as stories about people who got through those dark times. The number of people who positively adapt to life stresses far outweighs the number of people who do not, according to the National Action Alliance.
They conclude that those success stories may give hope to people with suicidal thoughts. The majority of people in their situation find a way to live. That might give them the courage to go on and keep looking for that way.
Suicides spiking during the holidays is a myth that comes back to haunt us every year.
The months of November, December and January actually have the lowest number of suicides per day, according to the University of Pennsylvania's Annenberg Public Policy Center, which analyzed 1999-2010 data from the Centers for Disease Control and Prevention (CDC). It found that averages were highest in the spring and summer.
There is still this sort of ironic thought that maybe there are people not happy at this time, according to the Public Policy Center. Songs and movies focused on the "holiday blues" -- including the perennial favorite It's a Wonderful Life -- also perpetuate the myth.
The center, which has tracked the media's reporting of suicides since 2000, looked at stories that linked suicides and the holidays. In 1999, 77% of those stories said, erroneously, that suicides increased over the holidays. The proportion of stories that supported that myth dropped after the center's analysis came out, but rose again last year to 76%.
The Public Policy Center tells us the return of the holiday-suicide connection may be related to the fact that the adult (ages 25 and older) suicide rate has increased in recent years in step with the Great Recession. With more people affected by suicide, news stories about suicide may be more common over the holidays, bringing the myth back to our attention.
In 2010, there were 38,364 suicides in the USA, an average of 105 a day. The month with the highest daily average in 2010 was July, with 111.3. The lowest, 98.2, was December. The CDC says suicide was the 10th leading cause of death in 2010.
Suicide-prevention experts say stories perpetuating the myth are not only wrong but dangerous.
The National Action Alliance for Suicide Prevention says that it's normal for people in their situation to end their life may be just that little nudge that puts them over.
They say anyone contemplating suicide should call the National Suicide Prevention Lifeline at 800-273-8255. Those who know someone in distress can call as well.
Media coverage needs to be more balanced. Coverage should include ways to prevent suicide, such as recognizing warning signs, as well as stories about people who got through those dark times. The number of people who positively adapt to life stresses far outweighs the number of people who do not, according to the National Action Alliance.
They conclude that those success stories may give hope to people with suicidal thoughts. The majority of people in their situation find a way to live. That might give them the courage to go on and keep looking for that way.
Women Notch Progress in Legal, Medical Fields
originally appeared in The Wall Street Journal:
In a major shift from a generation ago, women now account for a third of the nation's lawyers and doctors when those professions were occupied almost exclusively by men, new Census figures show.
Women's share of jobs in the legal and medical fields climbed during the past decade even as their share of the overall workforce stalled at slightly less than half. Women held 33.4% of legal jobs—including lawyers, judges, magistrates and other judicial workers—in 2010, up from 29.2% in 2000. The share of female physicians and surgeons increased to 32.4% from 26.8% during that time.
According to the president of the Institute for Women's Policy Research, a nonprofit group in Washington, that's very significant progress, in the midst of a lot of evidence that women's progress has plateaued, nevertheless we can see that women are still making progress in some very professional, high-wage fields.
Women's gains in these fields follow the rise in their professional school enrollments over time. Harvard Law School, for example, was closed to women until 1950, and the Washington and Lee University School of Law was the last U.S. law school to open its admissions to women in 1972, according to research by Hannah Brenner and Renee Newman Knake of Michigan State University's College of Law. Today, women graduate from law school in roughly the same numbers as men. They make up just under half—45.4%—of medical residents and fellows, or medical-school graduates in training, according to the American Medical Association.
A 26-year-old Miami resident said earlier generations in her family of Greek heritage believed women were meant to stay at home and raise children. While she was growing up, her mother didn't work.
But her parents emphasized the importance of getting an education to achieve a middle-class lifestyle. She earned a bachelor's degree in American history at Columbia University. During school, she worked part-time at a Manhattan law firm feeding off the energy of assisting on big cases, she said.
She graduated from the University of Miami School of Law last year and now is a commercial litigator. Two partners in the Florida firm where she works are mothers raising children, she said that for her, and for other women we're kind of just trying to get a start on our careers and focus on that.
Despite women's greater presence in law and medicine, wage gaps between men and women persist in both fields. In 2007, the median income—the point at which half earn more and half earn less—of female lawyers was $90,000, compared with $122,000 for male lawyers, according to research by Harvard economists.
The median income of female physicians was $112,128, compared with $186,916 for male physicians. Those differences are largely explained by individual choices, including women taking off time to raise children or opting for less-demanding career tracks or positions that pay less. But a small portion of the gap exists for unclear reasons. Discrimination could also be a factor, though it isn't clear how much, according to the economists.
One of the economists said women's gains in medicine have coincided with the rise of corporate-owned hospitals and medical practices, in many cases making it easier for women to balance work and family. Health-care companies have bought up many small, previously male-owned independent practices and raised women's wages closer to men's, while offering more flexible work schedules.
While women have made strides in the legal profession, at law firms few are taking management positions. Some leave for jobs as counsel to corporations, where hours can be more predictable. At large law firms, women make up just 15% of equity partners, according to a survey released in October by the National Association of Women Lawyers. Of the 200 firms surveyed, just 4% had a woman at the helm in the role of firm-wide managing partner.
A lawyer in Oakland, Calif., said biases against women were overt in 1975, when she graduated from the University of California Hastings College of the Law and started looking for jobs.
People would say directly, 'You can't be a lawyer because you're a woman, women are too emotional, their voices are too high,... they aren't tough enough,' she said women still face barriers to leadership jobs at firms, because advancement is largely based on hours worked. You're really trying to break into an established network, coming at it from the perspective of the woman, when most of the structures are designed by men.
A Michigan State University associate law professor, said while women graduate from law school in roughly the same numbers as men, many women leave the field for careers that offer more flexibility in hours and location.
The professor stated, as much as it's good to see the progress, she still remains troubled that we don't see a lot of our law graduates staying in the profession.
In a major shift from a generation ago, women now account for a third of the nation's lawyers and doctors when those professions were occupied almost exclusively by men, new Census figures show.
Women's share of jobs in the legal and medical fields climbed during the past decade even as their share of the overall workforce stalled at slightly less than half. Women held 33.4% of legal jobs—including lawyers, judges, magistrates and other judicial workers—in 2010, up from 29.2% in 2000. The share of female physicians and surgeons increased to 32.4% from 26.8% during that time.
According to the president of the Institute for Women's Policy Research, a nonprofit group in Washington, that's very significant progress, in the midst of a lot of evidence that women's progress has plateaued, nevertheless we can see that women are still making progress in some very professional, high-wage fields.
Women's gains in these fields follow the rise in their professional school enrollments over time. Harvard Law School, for example, was closed to women until 1950, and the Washington and Lee University School of Law was the last U.S. law school to open its admissions to women in 1972, according to research by Hannah Brenner and Renee Newman Knake of Michigan State University's College of Law. Today, women graduate from law school in roughly the same numbers as men. They make up just under half—45.4%—of medical residents and fellows, or medical-school graduates in training, according to the American Medical Association.
A 26-year-old Miami resident said earlier generations in her family of Greek heritage believed women were meant to stay at home and raise children. While she was growing up, her mother didn't work.
But her parents emphasized the importance of getting an education to achieve a middle-class lifestyle. She earned a bachelor's degree in American history at Columbia University. During school, she worked part-time at a Manhattan law firm feeding off the energy of assisting on big cases, she said.
She graduated from the University of Miami School of Law last year and now is a commercial litigator. Two partners in the Florida firm where she works are mothers raising children, she said that for her, and for other women we're kind of just trying to get a start on our careers and focus on that.
Despite women's greater presence in law and medicine, wage gaps between men and women persist in both fields. In 2007, the median income—the point at which half earn more and half earn less—of female lawyers was $90,000, compared with $122,000 for male lawyers, according to research by Harvard economists.
The median income of female physicians was $112,128, compared with $186,916 for male physicians. Those differences are largely explained by individual choices, including women taking off time to raise children or opting for less-demanding career tracks or positions that pay less. But a small portion of the gap exists for unclear reasons. Discrimination could also be a factor, though it isn't clear how much, according to the economists.
One of the economists said women's gains in medicine have coincided with the rise of corporate-owned hospitals and medical practices, in many cases making it easier for women to balance work and family. Health-care companies have bought up many small, previously male-owned independent practices and raised women's wages closer to men's, while offering more flexible work schedules.
While women have made strides in the legal profession, at law firms few are taking management positions. Some leave for jobs as counsel to corporations, where hours can be more predictable. At large law firms, women make up just 15% of equity partners, according to a survey released in October by the National Association of Women Lawyers. Of the 200 firms surveyed, just 4% had a woman at the helm in the role of firm-wide managing partner.
A lawyer in Oakland, Calif., said biases against women were overt in 1975, when she graduated from the University of California Hastings College of the Law and started looking for jobs.
People would say directly, 'You can't be a lawyer because you're a woman, women are too emotional, their voices are too high,... they aren't tough enough,' she said women still face barriers to leadership jobs at firms, because advancement is largely based on hours worked. You're really trying to break into an established network, coming at it from the perspective of the woman, when most of the structures are designed by men.
A Michigan State University associate law professor, said while women graduate from law school in roughly the same numbers as men, many women leave the field for careers that offer more flexibility in hours and location.
The professor stated, as much as it's good to see the progress, she still remains troubled that we don't see a lot of our law graduates staying in the profession.
Frankie Muniz, 26, tweets about his 'mini stroke'
originally appeared in USA Today:
Twenty-somethings having strokes? Yet that's what former Malcolm in the Middle star Frankie Muniz, 27 on Wednesday, says happened to him.
The young actor tweeted that he was in the hospital last Friday and suffered a "Mini Stroke", which he described as not fun at all. He said he’ll have to start taking care of his body! (he’s) getting old!
A lot of very specific information related to health, strokes, mini-strokes, and southfield stroke is also available online.
He did not explain why, and according to TMZ, doctors are still stumped, awaiting test results. TMZ says Muniz was taken to an Arizona emergency room after his friends became alarmed when they noticed he was acting strange, and having trouble speaking and understanding.
Specific explanations and information relevant to stroke and care for strokes is also at detroit stroke online resource.
What exactly is the difference between a "mini" stroke and major stroke? According to the Mayo Clinic, a mini-stroke is "transient ischemic attack (TIA)," a temporary interruption of blood flow to part of the brain. The symptoms of both are similar but a TIA doesn't destroy brain cells or cause permanent disability.
A mini-stroke can recur and each one increases the risk of another. Medication may be needed.
Twenty-somethings having strokes? Yet that's what former Malcolm in the Middle star Frankie Muniz, 27 on Wednesday, says happened to him.
The young actor tweeted that he was in the hospital last Friday and suffered a "Mini Stroke", which he described as not fun at all. He said he’ll have to start taking care of his body! (he’s) getting old!
A lot of very specific information related to health, strokes, mini-strokes, and southfield stroke is also available online.
He did not explain why, and according to TMZ, doctors are still stumped, awaiting test results. TMZ says Muniz was taken to an Arizona emergency room after his friends became alarmed when they noticed he was acting strange, and having trouble speaking and understanding.
Specific explanations and information relevant to stroke and care for strokes is also at detroit stroke online resource.
What exactly is the difference between a "mini" stroke and major stroke? According to the Mayo Clinic, a mini-stroke is "transient ischemic attack (TIA)," a temporary interruption of blood flow to part of the brain. The symptoms of both are similar but a TIA doesn't destroy brain cells or cause permanent disability.
A mini-stroke can recur and each one increases the risk of another. Medication may be needed.
12 December 2012
Colts coach Pagano finishes chemotherapy
Originally appeared in USA Today:
Chuck Pagano's return to the sideline this season remains a real possibility after the Indianapolis Colts head coach concluded a third and final round of chemotherapy Tuesday in his battle with leukemia.
I'm fully supportive, and I have my fingers crossed that he'll be there on the sideline if that's where he wants to be according to IU Health Simon Cancer Center said Tuesday evening.
That conceivably could be the regular-season finale Dec. 30 against the Houston Texans at Lucas Oil Stadium. The decision will be made jointly by Pagano and the organization.
ULTIMATE ASSIST: Bruce Arians steps up for Colts
According to IU Health Simon Cancer Center things are going well, he's received all of the chemotherapy he was to receive. Now it's just a matter of over the next couple of weeks recovering back to health. He can start conditioning and moving towards what he wants to do, which is return to coaching.
Perhaps as soon as Dec. 30?
The IU Health Simon Cancer Center states medically, (we) think it's very possible, and (we) think the coach will make the decision about how he's feeling and whether he's up to the task, then, the organization will make a decision.
It's feasible. It's possible. Is it definite? No. (we) definitely think that's where we're heading, and we have our fingers crossed that things go well and he's able to do it.
Pagano has been on indefinite leave since being diagnosed with leukemia Sept. 26. He endured three rounds of chemotherapy and felt well enough to attend the last two home games. It was announced Nov. 5 Pagano was in remission.
The IU Health Simon Cancer Center praised his positive approach throughout the process.
He's been amazing in terms of his focus, he's done well enough he's focused on his diet and his conditioning. He's done very well. But knock on wood. We've still got a couple more weeks to go.
Chuck Pagano's return to the sideline this season remains a real possibility after the Indianapolis Colts head coach concluded a third and final round of chemotherapy Tuesday in his battle with leukemia.
I'm fully supportive, and I have my fingers crossed that he'll be there on the sideline if that's where he wants to be according to IU Health Simon Cancer Center said Tuesday evening.
That conceivably could be the regular-season finale Dec. 30 against the Houston Texans at Lucas Oil Stadium. The decision will be made jointly by Pagano and the organization.
ULTIMATE ASSIST: Bruce Arians steps up for Colts
According to IU Health Simon Cancer Center things are going well, he's received all of the chemotherapy he was to receive. Now it's just a matter of over the next couple of weeks recovering back to health. He can start conditioning and moving towards what he wants to do, which is return to coaching.
Perhaps as soon as Dec. 30?
The IU Health Simon Cancer Center states medically, (we) think it's very possible, and (we) think the coach will make the decision about how he's feeling and whether he's up to the task, then, the organization will make a decision.
It's feasible. It's possible. Is it definite? No. (we) definitely think that's where we're heading, and we have our fingers crossed that things go well and he's able to do it.
Pagano has been on indefinite leave since being diagnosed with leukemia Sept. 26. He endured three rounds of chemotherapy and felt well enough to attend the last two home games. It was announced Nov. 5 Pagano was in remission.
The IU Health Simon Cancer Center praised his positive approach throughout the process.
He's been amazing in terms of his focus, he's done well enough he's focused on his diet and his conditioning. He's done very well. But knock on wood. We've still got a couple more weeks to go.
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