Saturday, January 26, 2008

Oregon Community Health Care Bill Fails to Deliver

The Oregon Community Health Care Bill purports to reform health care and health insurance in Oregon. Its primary sponsor, Richard Ellmyer is a John Frohnmayer supporter and features Frohnmayer on the same website that posts a version of OCHC. Frohnmayer is an independent candidate for US Senate, running against Gordon Smith.

Although Frohnmayer's position on healthcare is thus:

1. Any health care delivery system must be not-for-profit and run by the federal government on the national level and the State of Oregon on the local level.

2. Any system must allow the individual to choose his or her doctors and health professionals.

3. The system must increase the number of primary care physicians, pediatricians, and other health care professionals to deliver high-quality health services affordably, efficiently and equitably to the whole population.

4. The system must integrate all health care services and adequately pay for the best medical professionals. Doctors tell me now that they lose money on every Medicare patient. That is not a fair system.

OCHCB does not promote these lofty goals, in fact it prevents most of them (choice, access, reimbursement to primary care docs) from becoming reality. This bill is touted as a ‘moderate’ solution employing ‘market driven’ ideas.

Specifically, here’s what I don’t like about the Oregon Community Health Care Bill:

Is the most market driven health care plan in America.

Markets don’t work in health insurance. Markets force insurers to eliminate bad risks, expensive claims. Markets force insurers to become “evil”. Any insurance company that is ‘nice’ will attract people who need expensive coverage (because the ‘evil’ companies exclude them to be profitable, compete in the market) and thus ‘nice’ or ‘good’ companies will go out of business. (adapted from Krugman “Conscience of a Liberal”)

Here’s the quote from Krugman:

‘Insurance companies try to hold down those unfortunate medical losses in two principal ways. One is through ‘risk selection’ otherwise known, rather obscurely as ‘underwriting’. Both are euphemistic terms for refusing to sell insurance to people who are likely to need it—or charging them a very high price..Any indication that an applicant is more likely than average to have high medical costs and any chance of affordable insurance goes out the window.

If someone who makes it through the process of risk selection nonetheless needs care., there’s a second line of defense: Insurers look for ways not to pay…Insurers don’t do all this because they’re evil people. They do it because the structure of the system leaves them little choice. A nice insurance company, one that didn’t try to screen out costly client and didn’t look for ways to avoid paying for care, would attract mainly high-risk clients, leaving it stuck with all the expenses other insurers were trying to avoid, and would quickly go out of business. If the people doing all this aren’t evil, however, the consequences are [emphasis mine].’

I think this illustrates how markets aren’t a solution for health care. Health care has to be viewed differently in my opinion. We have to view it and HC insurance as something we as a society provide, like schools, social security, fire and police departments. Those things don’t make a profit either, but we have decided as a society that we should pay for them and not let ‘market forces’ provide.

This provision strikes me as odd:

Reduces health care costs to public institutions in Oregon by 20%.

Sounds great, right? Who’s not for reducing government spending. What’s buried later in the text is a not-so-clearly-spelled out scheme for this 20%. It looks like this proposal wants gov. employees to pick up 20% of their premium. Asking lower middle to middle income people (ie government workers) to shoulder a considerable expense (20% of your health insurance) when we are facing recession is poor policy.

This provision is crazy or just unrealistic to anyone who’s ever been near an Emergency Room:

5. The Oregon Health Plan shall not allow smokers to join.

So we’re going to solve the health care crisis by shifting the cost of smokers to hospitals? Do they think these people aren’t going to seek care when they have a respiratory crisis? The solution to helping these people is to not insure them? And who enforces the smoking ban? Are we going to have OHP ‘inspectors’ who visit suspected smokers’ houses? Smoking is an addiction and people often need help to quit smoking. But to deny these people treatment for hypertension, heart disease and COPD while their quitting (they have to be clean for 1 year before they’re eligible) is unusually harsh, punitive, and poor preventive medicine.

This is a retread: OHP used to function like this, perhaps it already still does:

13. Every two years the number of procedures covered by the Oregon Health Plan shall be reevaluated and shall include more or fewer procedures from the existing list.

OHP did this with procedure and meds. I remember fighting with them in the 90’s for a client that needed a proton-pump inhibitor (more effective) for managing Gastroesophageal reflux disease (GERD) but OHP would only approve H2 blockers like pepcid, which were ineffective in controlling this client’s disease. PPIs like prilosec were more expensive.

By stating this provision:

17. Health care providers licensed by the state of Oregon shall accept Oregon Health Plan patients for approved procedures.

The plan ignores the pitiful reimbursement rate of the OHP which effectively prevents members from finding doctors, thus denying care to members. Is this the health care we want in Oregon. To say oh, you’re covered don’t worry, but then you can’t find a doctor that is willing to accept your insurance? By legislating that health providers have to accept the OHP reimbursement rate we are shifting costs to primary care providers. They are already getting squeezed out and this mandate will mean there will be fewer in the future, and less primary care for Oregonians. Instead of squeezing PCPs, OHP should match medicare reimbursement.

This is a dumb business model idea:

18. 10% of the health care providers with the highest patient satisfaction ratings per year will receive a $10,000 cash incentive bonus. A minimum number of 300 votes or 60% of a health care provider's patients will be required to qualify.

Health care is not a popularity contest. Customer service is important, but improved health is a better measure of success than not having a grumpy receptionist to greet patients. In Sicko, Michael Moore profiled an English doctor that received a financial bonus if his patients had reduced hypertension, improved diabetes management or quit smoking. These are the kinds of yardsticks we should be using in evaluating how good a provider is.

Having said that I think there is a place for limiting health coverage, but based on scientific determination of a treatment’s effectiveness. The Community Health plan does not mention this but bases its approval of treatments solely on how much money is available. While this seems practical, it ignores the fact that medically sound treatments can reduce costs over the long run because the people get healthier!

This provision wants to limit patient’s rights in suing by having all medical malpractice lawsuits be vetted by a committee:

19. No member of the Oregon Health Plan may sue a health care provider for malpractice of a procedure allowed under the Oregon Health Plan without the express approval of five members of a nine member committee established for the specific purpose of determining the legitimacy or frivolousness of the proposed legal action. That committee shall be comprised of five permanent members serving four year terms namely, two retired judges, two retired physicians and the governor. The remaining four shall be chosen at random from the Oregon legislature each quarter prior to that quarter's meeting.

I deplore the use of defensive medicine (e.g. ordering extra tests to prevent lawsuits) and the increased costs associated with it, this would help, on the face of it, to lower such costs. This proposal wants a board composed of doctors, lawyers, judges and politicians, but what about representatives of the patients/insured? This committee should have an equal number of ‘permanent members’ from the members of OHP; 5 or 4 at least, that serve four years. This ensures that everyone’s interests are met and we are not screwing people for the sake of keeping costs down. It can also help to prevent this board from being used as a political tool by powerful lobbies such as hospitals or insurance companies.

So this plan would limit coverage, access to care, shift costs irresponsibly, impoverish already struggling PCPs and punish people with certain medical conditions (nicotine dependence). It’s a bad idea and one the legislature should reject.

UPDATE: I corrected this post to reflect that the Oregon Community Health Care Bill is NOT the same as SB329. The source I got the information from was incorrect and I didn't fact check. Thanks to the anonymous poster for correcting this error.

Wednesday, January 2, 2008

Maybe I was a bit hasty about Health Mandates...

I just read Paul Krugman's Conscience of a Liberal. He talks about health care reform and is a supporter of health care mandates proposed by presidential hopefuls Clinton and Edwards. Obama has a similar funding scheme without mandates.

I blogged recently that I didn't like this plan as it required by law everyone to pay for health insurance. In that post, I linked an article that argued against mandates for reasons of cost. Poor people can't afford health insurance.

After reading Krugman's book, I realize that this is a mischaracterization of his position. Two elements of the mandate plan would keep down costs for poor people: subsidies and community rating. Subsidies fund the insurance cost for the unemployed and poor and community rating means that insurance companies have to charge the same premium for everyone.

Another element, public/private competition creates incentives to keep premium costs low.
As Krugman notes, it is much more complicated than a single payer system, which the American Nurses Association supports. However, given the expected overwhelming opposition from insurance and drug companies, it is the plan that can be passed in the current political climate.

Because it would create health insurance coverage for all Americans and it is the plan that has the greatest chance of politically surviving, I have to reverse my earlier position and support a health insurance scheme with mandates.

Monday, December 10, 2007

OHSU's Gleevac still works on Leukemia

Gleevac was found to increase life expectancy in ALL leukemia patients. Gleevac is a new type of drug, I learned in a recent pharmacology class that it actually changes two sections of chromosome that promote the disease. It's exciting to me because drugs that target faulty genetic code can actually cure cancer, unlike current treatments that don't address the underlying cause, bad DNA. Now, if we could only prevent our DNA from getting so f*&!'d up to begin with..

Health Care Reform: Health Mandates vs. Universal Health Care

Health Mandates are features of health care reform plans proposed by Hillary Clinton and John Edwards. Barack Obama has floated a plan without mandates. What are these mandates you ask? They are a requirement that people buy health insurance like car insurance.

There are several problems with this idea. One is cost. The linked article mentions these plans costing 10% of a person's income. This would not be supported by people getting employer sponsored health care for free or people without insurance but who can't afford 10%.

It's unfortunate that no major candidate is proposing universal health care. The American Nurses Association supports universal hc but apparently this is too far left to be considered by the so-called mainstream (read 'just right of center') Democratic candidates.

I think of health care like school districts, police, and fire departments. Could you imagine a fire department not responding to a fire because it wasn't profitable? Yet people are doing the same thing with health care.

Sunday, December 9, 2007

Pamplin News: 'Emanuel Losing Accreditation?' Not

The Spotlight, a Pamplin Media-Owned newspaper, states on 12/4 that Emanuel followed incorrect restraint and resuscitation procedures in the death of Glenn Shipman. What the story fails to mention is that textbook procedures may have been difficult with this patient since he was 450 lbs., psychotic and had been tasered by police prior to hospitalization. None of that justifies negligent care of course, but it does underscore the difficulty of caring for such a patient.

The article also mentioned that Emanuel was losing its JCAHO certification. According to an indirect source (the spouse of an Emanuel employee), Legacy sent an email to its employees stating that Emanuel has passed JCAHO certification.

Saturday, December 8, 2007

I'm no "scab"!!

Let me start by saying I hate telemarketers. All telemarketers. But by far the worst are the dregs of society calling me lately from "nurse staffing" companies. They offer obscene amounts of money to work at hospitals where nurses are on strike.  In other words to be a "scab". 
I have several problems with this. First of all, those nurses are striking for fair wages, safe staffing ratios, benefits and other reasonable demands. Secondly, if the hospitals can afford to pay "scabs" the wages they are offering, they can certainly afford to negotiate with the nurses on strike. Thirdly, I hear all kinds of rational for nurses crossing picket lines; "The patients still need care", "Someone still needs to work" ,"I need the money". I disagree with all of these excuses. Nurses should have one of the strongest political voices in the United States today. Crossing picket lines is one of the reasons we don't. It isn't good for us and it isn't good for our patients.
So, all you telemarketers stop calling me. I'm no "scab"!!

National Nurse