Health

While I was tied up with work and travel, a couple of interesting stories made it into my reading pile.  Together, they convince me that the concept of personal responsibility must be virtually illegal.

First, I saw this article in the Wall Street Journal (subscriber link):

Ian Perry, a Los Angeles city-council member, is spearheading legislation that would ban new fast-food restaurants like McDonald’s and KFC from opening in a 32-square-mile chunk of the city, including her district. The targeted area is already home to some 400 fast-food restaurants, she says, possibly contributing to high obesity rates there — 30% of adults, compared with about 21% in the rest of the city. Nationally, 25.6% of adults are obese, according to the Centers for Disease Control and Prevention.

While some cities have bans on new fast-food establishments, they typically are for aesthetic reasons or to protect local businesses. Ms. Perry’s initiative seems to be a rare instance in which a major city brings health issues into restaurant zoning. The fast-food ban would last a year, although Ms. Perry hopes to make it permanent. On Tuesday, a committee will make a recommendation on the measure before sending it on to the full city council for a vote.

I have to admit that I’m not particularly opposed to the idea of fewer fast food restaurants around.  The use of zoning laws to support a public health issue is the sort of creativity I appreciate.

But then, we have this story in the New York Times:

Gov. Arnold Schwarzenegger signed legislation Friday that will prohibit restaurants and other "food facilities" from using oil, margarine and shortening containing trans fats.

The intent is certainly admirable…but in the land of the free and the home of the brave, aren’t people permitted to make their own personal decisions?  Doesn’t freedom include freedom to make bad decisions, provided we accept the risk/consequences?

I’ve written several times in the past on my frustration that the powers- and pundits-that-be seem to focus on some folks’ lack of health insurance as being “the problem”, while failing to consider the real problem – that the health care Americans have come to expect is just so damned expensive.

I’ve just read an article (subscriber link) in Tuesday’s Wall Street Journal which does a great job of highlighting the expense problem:

American doctors rarely used to let costs factor into their treatment decisions. But rising prices — some cancer drugs now cost more than $100,000 a year — are dramatically changing that ethos in the field of oncology. Money issues are now disrupting relationships with patients, causing doctors to go into debt and threatening to interfere with treatment options.

Unlike most physicians, who write patients prescriptions that they can fill at a pharmacy, oncologists must buy many drugs upfront because they’re delivered intravenously in the office. As a result, doctors are on the hook until patients or insurers pay the bill. Reimbursement delays and denials are now more common as insurers clamp down on claims. Some patients can’t afford high co-payments.

"Twenty years ago, when I was in training, nobody really dealt with economics," says Stephen Hufford, an oncologist in San Francisco. The prevailing thinking, he says, was: "Cost should never be an issue in someone’s care."

That approach increasingly looks untenable. In February, after delays in payments from insurers, Dr. Hufford was working to pay off several hundred thousand dollars of past-due bills to his drug distributor. When he ordered $20,000 of chemotherapy for three patients he was to see the next day, he says the distributor refused to deliver the drugs unless he paid in advance and reduced his outstanding balance by another $20,000. He didn’t have $40,000 in his bank account.

With the general election campaign heating up, I expect that we’re going to hear more about “the uninsured problem” in the not too distant future.  I still say that focusing on that problem seems kind of short-sighted unless policymakers and the public in general don’t start looking at the entire system of financing health care, the costs involved…and perhaps what level of care is supposed to be provided as an apparent “right”.

In a prior job, I had the dubious honor of being, in some folks’ minds, the embodiment of evil – working with consumer credit data in insurance pricing, poking around in summaries of consumers’ financial transactions to see what could be learned about their behavior.  (Yes, most of my work was anonymized and done in such a way as to not impact consumers’ live files…but I’m sure that some consumer advocates would actively disbelieve the truth there.)

That experience, along with my own quasi-libertarian, pro-privacy paranoia of accumulations of data in the wrong hands, has caused me to advocate certain protections be implemented in collections of personal information – in particular, the maintenance of records where an individual can see who accessed what information for what reason.  It’s standard operating procedure in some databases, but it’s not universal.

So, I was very pleased to see a comment on the subject in this Business Insurance article discussing an agreement on standards of developing electronic accumulations of personal health data:

U.S. consumer groups, insurers and privacy advocates, together with Google Inc. and Microsoft Corp., on Wednesday said they have agreed to standards intended to speed adoption of personal electronic health records.

The electronic medical record field remains in its infancy. While U.S. privacy laws govern actions by medical providers like doctors, there is little in the way of other established privacy, security and data usage standards despite decades of industry effort.[…]

Principles for personal health records include an audit trail to track use of the data, a dispute resolution process for consumers who believe their personal information has been misused and a ban on using data to discriminate in employment.

Also signing on to the principles are WebMD; Consumers Union, which publishes Consumer Reports; AARP, the seniors’ lobbying group; and America’s Health Insurance Plans, which represents major insurers such as Aetna Inc

I am still leery of the development of massive databases of such personal information, but at least it looks like the folks pushing it are on the right path on certain security aspects.

However, I do still wonder about the efficacy of such databases, given that there seems to be many different players building their own “solutions”.  Won’t there be a problem with the balkanization of the universe of personal health data?   Perhaps the next high-level agreement needs to be some collaboration on import/export standards….

Seen in the Commercial Appeal:

Since taking effect Oct. 1, the Non-Smokers Protection Act has prohibited smoking in most enclosed public places. Exemptions include bars and other age-restricted venues and hotels and motels, which are allowed to designate one-fourth of their rooms for smoking. Violations can result in fines of $500 per day.

Some 36 businesses across the state are appealing violation notices, said Carter Garner, assistant director of the division of general environmental health for the Tennessee Department of Health. But Memphis International is one of the highest-profile cases and the only one involving an airport.

Garner said health officials believe smoking can’t be allowed at the airport businesses because “they are enclosed facilities within an enclosed facility.” [...]

At the two bar-restaurants, the airport installed negative-pressure filtration systems designed to suck tobacco smoke outside. Officials say the systems — installed years before the law took effect — make the air as safe or safer than anywhere else in the airport.

You know, with the TSA’s recent emphasis on observing the behavior of airport patrons to spot potential evil-doers, you’d think that there would be a bit of a security emphasis placed on keeping ordinary travelers as relaxed as possible, and traffic passing through security lines reduced to the absolute minimum possible.

I’m not a fan of smoking, but I have been around smokers going through nicotine withdrawal after a long flight… and I’d think that perhaps having an appropriately-ventilated smoking area in the secure area might not be the worst idea in the world.

Heck, the way that airlines have been looking for any way to squeeze out extra revenue…airline-sponsored smoking lounges, anybody?

One of the accomplishments the Connecticut state legislature is proud of for this past legislative season is a new law which would permit small businesses, nonprofit organizations, and towns to join the pool insuring state employees.

However, it seems like legislators might have forgotten about actuarial and economic realities in the measure.  From the Courant:

On Monday, Rell released a letter from Anthem Blue Cross and Blue Shield of North Haven that said the insurer would be forced to increase its rates by 4 percent — or more than $24 million — for the fiscal year that starts July 1.

Anthem President David R. Fusco said “we must also rescind the second- and third-year rate caps for 2009 and 2010″ that the company had agreed to in its three-year bid to provide health insurance for state employees.

Since the bill would open the pool to more than its current clients, Anthem says that is “a material change to the underlying assumptions of the bid” and allows it to recalculate the bid.

Oops.

Once the dust settles on incremental gains from marketing  arrangements and volume efficiencies, not to mention the shuffling of dollars to cover uninsured patients and uncollectable bills, the fact remains that certain populations are fundamentally more or less expensive to underwrite than others.

If a group is receiving a low rate due to a better expectation of future results, and the doors are opened to higher-risk insureds…well, the difference in cost is going to have to be made up someplace.   The net result may be beneficial for some, but others will definitely be left with a higher bill.

That is, of course, one of the challenges facing the country in the current health care debate.  While many (most?) folks would love to see everyone have access to affordable healthcare, frequently through some form of a universal health care plan….the details are a little fuzzy when it comes to generating a credible estimate of how much it’s going to cost, and exactly who is going to pay how much to make that happen.

Judging by this article in the Independent, I smell another round of debate coming regarding cell phones and health:

A giant study, which surveyed more than 13,000 children, found that using the handsets just two or three times a day was enough to raise the risk of their babies developing hyperactivity and difficulties with conduct, emotions and relationships by the time they reached school age. And it adds that the likelihood is even greater if the children themselves used the phones before the age of seven.[...]

They found that mothers who did use the handsets were 54 per cent more likely to have children with behavioural problems and that the likelihood increased with the amount of potential exposure to the radiation. And when the children also later used the phones they were, overall, 80 per cent more likely to suffer from difficulties with behaviour. They were 25 per cent more at risk from emotional problems, 34 per cent more likely to suffer from difficulties relating to their peers, 35 per cent more likely to be hyperactive, and 49 per cent more prone to problems with conduct.

The scientists say that the results were “unexpected”, and that they knew of no biological mechanisms that could cause them. But when they tried to explain them by accounting for other possible causes – such as smoking during pregnancy, family psychiatric history or socio-economic status – they found that, far from disappearing, the association with mobile phone use got even stronger.

You know, we’ve had a bumper crop of baby bumps in my office this spring.  I’m reminded of just how many ladies in the office will chat on their cell phones while walking outside at lunch…or of the guys in the office whose young children will call them on the cell phone when picked up from day care….

A passage in a Wall Street Journal article (subscriber link) caught my eye:

On TV one night, Mrs. Kelly saw a news segment about people who try to get patients’ bills reduced. She contacted Holly Wallack, who is part of a group that works on contingency to reduce patients’ bills; she keeps one-third of what she saves clients.

Ms. Wallack began firing off complaints to M.D. Anderson. She said Mrs. Kelly had been billed more than $360 for blood tests that most insurers pay $20 or less for, and up to $120 for saline pouches that cost less than $2 at retail.

On one bill, Mrs. Kelly was charged $20 for a pair of latex gloves. On another itemized bill, Ms. Wallack found this: CTH SIL 2M 7FX 25CM CLAMP A4356, for $314. It turned out to be a penis clamp, used to control incontinence.

M.D. Anderson’s prices are reasonable compared with other hospitals, Mr. Tietjen says. The $20 price for the latex gloves, for example, takes into account the costs of acquiring and storing gloves, ones that are ripped and not used and ones used for patients who don’t pay at all, he says. The charge for the penis clamp was a “clerical error” he says; a different type of catheter was used, but the hospital waived the charge. The hospital didn’t reduce or waive other charges on Mrs. Kelly’s bills.

Maybe hospitalization should include a “BYOMS” — Bring Your Own Medical Supplies — option?  Sheesh!

In fairness, I can understand hospitals’ need to make up revenue gaps from providing care to those who can’t make good on their bills, as well as to satisfy investors if the hospital is a for-profit operation.   But isn’t a 60-fold increase in the cost of a saline bag a touch extreme?

Oddly enough, that passage appears in an article discussing a new trend in American hospital care of requiring payment up-front (a practice that apparently leaves quite a bit to be desired in the implementation), which would seem to curtail a decent chunk of the problem of nonpaying patients.

I hope I’m not alone in thinking that “universal health care” as a tool to reduce health care costs in the country is only a piece in the puzzle.  Some of the wacky billing practices and inefficiencies involved therein have got to introduce a drag on the entire system.

Seen in the Wall Street Journal (subscriber link):

After more than a decade of deliberation, the Senate cleared the bill 95-0 Thursday. The same bill is expected to sail through the House early next week — just as a similar measure did a year ago — and on to President Bush, who is expected to sign it.

The legislation would bar insurance companies from denying health coverage or charging higher premiums based on a person’s genetic information. It would also bar employers from using genetic information to make hiring, firing and other job-placement decisions. It applies to people who have genes that carry the risk of disease, but not to those who already have the disease.

I will admit that my initial reaction was one of fears of adverse selection.  However, that was quickly reined in.  Given that everybody who can get health insurance should have some coverage, there aren’t too many folks who would opt out of the system altogether.   And, it’s not inconceivable to imagine how the potential for better diagnosis and more targeted monitoring and early detection of potential health issues could lead to a net savings for the system overall.

I was looking forward to watching Frontline this week after seeing this comment posted at Balloon Juice:

This weeks edition of Frontline will cover health care around the world. They have a few trailers up, and it looks to be quite good.

Sure enough, the program guide for the national PBS feed provides the following description for this week’s Frontline:

Sick Around the World The healthcare systems of other advanced democracies could provide the United States with ideas as to how to reform its healthcare system.

…unless one’s local PBS outlet is Connecticut Public TV. This week, CPTV will carry a different episode of Frontline:

Growing Up Online The impact of the Internet on adolescence focuses on children who are harassed or bullied and those who gain attention on YouTube.

I’m sure that this discrepancy is purely coincidental given the underwriting provided CPTV by certain Hartford-based insurers, right?

I’ll break out the rabbit-ears to pick up a Massachusetts signal, or see if I can download the episode later this week, I guess.

Seen in a Boston Globe blog:

The state’s new subsidized health insurance program will cost “significantly” more than the $869 million proposed in the governor’s FY2009 budget just two months ago, the state’s top financial official said today.

The budget gap looms despite steps taken today to hold down state costs—approval of a tough contract with insurers, and increased premiums and copayments for about half of the 176,000 people enrolled.

The monthly premiums and copays are still modest for low income folks in the state plan. However, I wonder how long it will be before my big fear about state health plans—that the state is obliged to regulate or levy taxes to combat health care costs—starts to come true.