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Health Wonk Review: Crunch Time For Health Reform

Last Updated Jul 8, 2009 8:41 PM EDT

As Congress faces America's healthcare demons again, I have the honor of hosting this biweekly review of some of America's best healthcare bloggers. They include Joe Paduda of Managed Care Matters, who helms a subsection of this Health Wonk Review devoted to initial reactions to Bob Laszewski's unusual reform proposal. That mini-section follows the main body of HWR.

Our first topic is the employer role in reform, which is getting more attention lately. In "Taxing Health Benefits--a Lose-Lose Proposition," Merrill Goozner of GoozNews lays waste to the notion--now under consideration by the Senate Finance Committee--that "gold-plated" health benefits are ripe for taxation because they're overly rich. As he points out, many employers offering expensive group plans are in high-cost areas and/or have older and sicker employees.

The Health Access Blog, in "Making sense and cents of the employer role in reform," succinctly compares the House committees' and Senate HELP Committee's versions of a pay-or-play employer mandate. Both would exempt small businesses, but the Senate version would encourage employers to limit workers' hours and give some larger firms with mostly part-time help a tax credit for covering them.

Anthony Wright, writing for The New Republic's The Treatment, argues that the employer assessment for health coverage should be set higher than it is in the Senate HELP legislation, reminding us that a similarly low penalty for non-coverage has contributed to Massachusetts' fiscal mess. He favors the House bill's provision requiring employers that don't cover their workers to pay 8 percent of payroll into a health fund.

Meanwhile, the public option continues to generate intense debate. Jaan Sidorov, an iconoclast who previously took his hammer to health-IT-as-salvation, takes a similarly skeptical view of the public plan at the Disease Management Care Blog. After casting cold water on several assumptions of public plan supporters, he envisions that insurance might eventually become a three-tiered system of "underfunded Medicaid," a "one-sized-fits-all" public plan for the middle class, and "gold-plated" private insurance for the elite.

Over at Health Beat, Maggie Mahar asks, "Does It Matter Who Pays For Care? Who Has The Standing To Set Limits?" Responding to Atul Gawande's assertion in his recent New Yorker article that it is provider accountability, not the source of payment, that is essential for reform, Mahar notes that for-profit health plans have never had the moral authority to set limits on care. But a Federal Health Board, she asserts, could use comparative effectiveness research to establish coverage guidelines that doctors and patients might abide by, and a public plan would follow them. Of course, private insurers would probably do the same, to judge by their conformance with Medicare coverage decisions.

On another front, Medicare's recent proposal to increase primary-care payments by 6-8 percent at the expense of specialists has angered some physicians. "Cardiologists React Badly to Proposed Medicare Payment Cuts," notes DrRich on The Covert Rationing Blog. A cardiologist himself, DrRich observes that the AMA committee that advises CMS on how to divide the physician pie was always stacked against generalists; but he doubts that an 8 percent pay boost will induce many physicians to enter primary care.

In brief, here are some other blogs worth visiting:
  • Jason Shafrin at The Healthcare Economist looks at how Dutch hospitals operate. Despite having budgets, their costs are rising 6 percent a year.
  • David Harlow's Health Care Law Blawg embraces "A Declaration of Health Data Rights," but says it's only a first step.
  • Rita Schwab at Supporting Safer Healthcare considers Consumer Union's assertion that hospitals have made little progress in improving safety since the Institute of Medicine published "To Err Is Human" a decade ago.
  • At New America Foundation's New Health Dialogue Blog, Joanne Kenen observes that the high readmission rate at U.S. hospitals is a major cause of over-the-top health costs. Her best point: patients discharged from the hospital may have long waits for outpatient doctor appointments.
  • Tom Lynch at the Workers' Comp Insider praises Gawande's article extravagantly, while Evan Falchuk, in "The McAllenization of Health Care Reform," makes the obvious but essential point that the article doesn't serve up all the solutions we need to fix our hugely complex mess of a healthcare system.
  • Louise at the Colorado Health Insurance Insider provides another piece of the puzzle in "Surgery Might Not Be Best For Breech Births," a timely reminder that far more caesarian sections are performed in the U.S. than anywhere else.
  • On Neil Versel's Healthcare IT Blog, Versel describes what he views as the AMA's reactionary attitude toward the government's health IT campaign.
  • Tinker Ready at Boston Health News reveals the health care connection to Bernie Madoff in a post about major donors to Boston hospitals.
And here's Joe Paduda's mini-section on Bob Laszewski's proposal.

The Affordability Model - Reactions From the Blog-o-sphere Amidst all the to-and-fro about the public plan option, taxing health benefits, cost control and how many uninsured this plan or that plan would cover, there have been all too few new ideas. And fewer still that have much promise.

Bob Laszewski's "Affordability Model" is definitely new, and according to some, may have a lot of promise. Introduced late last week, the Model has sparked interest both on Capitol Hill and in the blog-o-sphere.

Briefly, Laszewski's idea is to name a national health board that would set overall goals for health cost inflation. Each health plan would then be measured on its ability to keep cost growth below that rate, and the ones that can't lose their tax deduction for employers and their tax exemption for employees. There's no public plan option, no national board certifying medical procedures or setting rates. There's a good deal more to it - here's where to find a detailed discussion.

HWR host Ken Terry is of the opinion that the AM "proposal has many strengths--not the least of which is that it does align the incentives of all the major stakeholders. It does not rely on global budgeting, across-the-board fee cutting, or government-imposed rationing."

I like the Model because it avoids the polarizing issue of the public plan and mitigates the taxation argument. I'm also hearing that it is under serious review by both Congressional staffers and elected officials.

Hank Stern at InsureBlog doesn't much care for the Model; even though he thinks Bob is one of the brightest of the health wonks, he finds much to not like about the plan, including the big role for government. Not sure where Hank is seeing the big gummint role; outside of a board to set the goal, it's up to the private insurers to figure out how to hit the target.

And Michael Millenson over at The Health Care Blog doesn't think the Model factors in political reality; specifically, the tone and content of the current debate precludes its adoption, he says.
  • Ken Terry

    Ken Terry, a former senior editor at Medical Economics Magazine, is the author of the book Rx For Health Care Reform.