During his short stint at UC Berkeley, Professor Orszag had a way to calm exam anxiety amongst frazzled economic undergraduate students. Now he is charming, front and center, the two largest public health care financiers, Medicare and Medicaid. He always enjoyed the public policy limelight, and he made that no secret by flashing photos of him at the President’s Council of Economic Advisers meetings. He never voiced his passion in health care, but I suppose budget, policy, and rationale for economics are parallel with a more tangible health care subject. Best to him!

U.S. News: CBO Chief Is Health-Care Referee — Peter Orszag Takes A High Profile On Crucial Issue

By Anna Wilde Mathews
1039 words
21 April 2008
The Wall Street Journal
A4
English
(Copyright (c) 2008, Dow Jones & Company, Inc.)

As the presidential candidates and Congress rev up the debate over the future of health care, Peter Orszag is already playing one of the toughest positions: referee.

Mr. Orszag, a 39-year-old economist, is the director of the Congressional Budget Office, the influential agency charged with toting up congressional bills’ impact on the federal budget. Such scoring can sink bills that can’t offset their costs with savings — a serious risk for proposals that aim to expand federal health programs to cover more citizens.

Mr. Orszag increasingly is focusing on health issues, taking an unusually high profile for his nonpartisan office. He has become a prominent speaker at health conferences and co-wrote two pieces in the New England Journal of Medicine. He has launched a blog, cboblog.cbo.gov/, boosted the number of staffers who work on health to 47 from 31 and is seeking to add more. The agency has 235 employees.

“This actually is our fiscal future, and policymakers do not have as much analysis and options as they would need to make sound long-term decisions,” says Mr. Orszag.

Mr. Orszag wants to drive home concerns about what he says are the “unsustainable” current growth rates of Medicare and Medicaid. Over his desk hangs a chart showing projected growth in federal spending on the two programs, which together are projected to represent 9% of gross domestic product in 2035 and 19% by 2082. Currently, they constitute 4% of GDP, or nearly $600 billion in federal spending for 2008. The Medicare trustees have said the elderly-insurance program’s hospital trust fund is on track to run out in 2019.

Though Mr. Orszag, who worked in the Clinton administration, steers clear of presidential politics, his office could play a key role in the fate of the next president’s efforts to re-organize the health-care system. Because of the sharply different approaches of Republican candidate Sen. John McCain and the two Democrats, Sens. Hillary Clinton and Barack Obama, health plans will likely be a significant policy clash in the general election this fall. And the work the CBO is doing now may provide ammunition to one side or the other, as it examines different potential approaches.

The CBO director, who started his four-year term in January 2007, is going beyond the traditional budget-Cassandra role, and analyzing causes and solutions. He has emphasized that the biggest driver of rising medical costs is the increasing use of new technology, not simply an aging population. Mr. Orszag likes to present a slide show that highlights geographic variations in Medicare spending — which, he points out, don’t clearly correlate with healthier people.

“Peter has helped change the focus in health-care-policy debates to the delivery system,” says Mark McClellan, who headed the federal agency that oversees Medicare and Medicaid during the Bush administration and is now based at the Brookings Institution.

Mr. Orszag, who didn’t focus on health care in his own research at Brookings and elsewhere, says he found “astounding” the gaps in spending between particular hospitals that emerged in Dartmouth Medical School research. “We’re paying twice as much at one place as the other and we have absolutely no idea what we’re getting in exchange for it,” he says.

The CBO has released an analysis on the hot-button topic of “comparative-effectiveness research,” which weighs different medical treatments. The analysis generally took a favorable view toward such research as a means of reducing costs. The office is scheduled soon to release an analysis on information technology, likely exploring the evidence for its usefulness and its possible budget effects.

The CBO’s health-care work “will be very instructive to members when we attempt to take steps to right the ship,” says Sen. Kent Conrad, the North Dakota Democrat who chairs the Senate Budget Committee.

Like all CBO directors, Mr. Orszag gets constant prodding from lawmakers eager to play up their bills’ budget savings, and the stakes will be far higher for any major reorganizational legislation. In 1994, then-CBO director Robert Reischauer famously testified that the Clinton health plan would cost the federal government far more than the White House projected, resisting pressure to score it more favorably. The testimony was a serious blow to the plan.

“Because the CBO plays such a critical role…of course what he says will have a big impact,” Mr. Reischauer, now president of the Urban Institute, says of Mr. Orszag.

Because many of today’s proposals haven’t been tried before, it is particularly challenging to model — and easy to argue — their likely effects, economists say.

“Effective policies to increase access to health care, and to improve the quality of that care, have far-reaching effects on our economy,” says Sen. Edward Kennedy, the Massachusetts Democrat who chairs the Senate health committee. “It’s essential for the Congressional Budget Office to take this complexity into account in analyzing health legislation.”

Conversely, the office can face second-guessing when it does chalk up some savings. Joseph Antos, a former CBO official who is now at the American Enterprise Institute questioned the CBO’s decision to attribute at least some potential offsetting savings to comparative effectiveness.

The upshot was that at the end of a 10-year span, the project would effectively break even. “The great tradition of CBO has been that if there wasn’t clear evidence on some proposal, the response was, ‘We won’t give you a score,’” Mr. Antos says. “The evidence is simply not there, by my reading.”

Mr. Orszag says he is seeking to battle perceptions that the CBO doesn’t adequately take potential savings into account. He has heard more objections about the CBO being too stingy in its analysis of the comparative-effectiveness provisions, he says.

In general, he says, “we should give our best estimate on either side.” His background in an academic family — son of a Yale math professor; brother of two other Ph.D economists — prepared him to weather such arguments, he says.

This past week, SFGate announced that San Francisco’s Mayor Gavin Newsom’s administration and coalition are outraged by the 10% Medi-Cal physician reimbursement implemented by Governor Schwarzenegger’s Medi-Cal wonks (article 1 and article 2). This desperate $600 million savings attempt by the State government is plan B after Governor Schwarzeneggar’s Medi-Cal reform failed to come to fruition.

Being in the Medicaid field, I have no idea how Mayor Newsom’s lawsuit can stand legal grounds. Burden of health care access? By cutting reimbursement, physicians who can forgo the slim Medi-Cal reimbursement margins will bar medical services to existing or new Medi-Cal patients. If this financial barrier to health care access can be shown, then the new decreased reimbursement is not actuarially sound. If this cut had to be approved by the Center for Medicare and Medicaid Services (CMS), then an actuary’s signature must have certified the rates to be sustainable for the current level of access or greater. Obstruction to access is difficult to prove because of the intangible definition for the highly fluid Medi-Cal population. In addition this is only arguable for managed care but not for the fee-for-service system. The testy lawsuit stands weak legal grounds.

Can anyone with more policy and legal field experience enlighten me on the legal argument of this lawsuit?

In my mind, if Mayor Newsom wants to become Governor Newsom, this lawsuit is more of a political platform building opportunity for the 2010 election. I really hate seeing charismatic politicians that have the power to do wonders but then become a disservice to the American public, and I think Mayor Newsom thinks so too. So I nailed my opportunity yesterday to put in a plug. I really did not want to seem like every other San Francisco business person in line to shamelessly plug their business and that is it. I wanted to tell him how I could be part of his A-team of civil servants to make his health care policy progressive, hospitable, and vastly improved. So what did I do?

I am very gracious that my firm participated in the city planning team for San Francisco Earth Hour. In exchange for volunteering for the event by handing out energy conservation incandescent light, I earned an invite to the kick-off event at MarketBar where I knew that the Mayor had a public appearance.

I sealed the deal by thinking of two main points to capture his coveted attention. Point one was to get him engaged: Do you recall a few months ago when you rode the N-Judah Muni Metro to work?

My witness to his N-Judah presence provoked his outrage on the city’s MUNI issues. His knowledge of the issues and detailed ridership numbers impressed my friend whose husband has a MUNI love and hate relationship. As he pointed out the electric MUNI car parked outside of MarketBar, I took a jab that Austin long had these buses, and the vehicles are cleaner, wider, and more comfortable. That comment sparked Mayor Newsom’s competitive sportsmanship. San Francisco can do much better than Austin!

Point two was to hit his health care policy interest dead-on. I had a little trouble plugging myself because I am very shy, too polite, and passive. So my friend helped me out by shouting that I had health care policy interests. That grabbed his attention and he asked, “Did you know that we are suing the governor for their Medi-Cal cuts?” I thought, “Duh!?” Which health care policy wonk did not. So I put in my plug for what my team did for the current Governor’s administration on Medi-Cal redesign. He asked for my business card, and I sincerely hope his administration follows up.

If Mayor Newsom is going to be the next Governor, I want my hand at health care reform done right the first time his administration proposes it. I am sick and tired of living through stale iterations of reform, issue attrition, and waning political momentum. I am also sick of complaining. While young and capable, I have the time, patience, and aptitude, and I hope I get in on the action.

On a separate note, the Governor learned from former First Lady’s Hillary Rodham Clinton’s political debacle at health care reform. Since 2004, the Governor had various task forces to gather genuine buy-in, extensive input, and productive discussions. PR wise, “redesign” appears to be a more salient policy term than “reform.” This was one of my first health care policy field work assignments. I will save this story for another day but feel free to browse through one sliver of the redesign planning at the California Health Care Foundation. I am just sad that with all the effort, blood, sweat, and tears, plan A failed, hence this slapped together Plan B to help salvage the State’s budget. Not surprising, a lawsuit abounds.

There are many catch-22’s in the health care system. A managed care company reimburses providers and hospitals for services rendered to beneficiaries at a certain payment level. The payment is just enough for hospitals and providers to maintain a contractual relationship with the managed care company and just enough for the insurance company to expense the least possible reimbursement to maximize profits. This reimbursement amount is a major factor in maintaining a large and stable network of providers that beneficiaries can choose from and can easily obtain care. The catch? Only if the payment is enough!

Access to health care is important. If you were taught under the same school of thought, the Five A’s of ACCESS are affordability, availability, accessibility, accommodation, and acceptability.

Affordability
Are you willing to pay what the provider is willing to accept or is the provider willing to accept to what you are willing to pay? Even if people were to pay by means, most people could not instantly pay off a health care bill. Perhaps a person may be able to pay over a long period of time like they do with their monthly mortgage and car payments, but since most people do not physically see their health care value like they do with their car everyday, most of these bills may end up at the collection agency. Thus affordability often equates to whether or not a person is insured and can afford to pay insurance premiums to the insurance company that really pays what the provider is willing to accept.

Availability
Can you see your physician immediately or do you have to wait 3 months to a year in order to get in for your annual exam? Does the physician have adequate and up-to-date technology and knowledge to perform his or her duties? Does the practice employ enough practitioners and personnel to have an efficient and smooth visit?

Accessibility
Are they local and easy to get to? Or is the next closest doctor more than an hour away?

Accommodation
Are the providers available when you need them? Do they have appointments available beyond regular business weekday hours and weekends? Optometrists and dentists tend to offer more available hours than general practitioners. Does you doctor make night calls like France’s SOS Médécins. San Francisco’s On Call Medical Group, albeit expensive, does make urgent individual night calls, which can circumvent an unproductive long wait at the emergency room.

Acceptability
Do the providers openly accept you the way you are without passing judgment? Oftentimes providers presume they know best for the patient not only for medical advice but for your social and economic welfare.

In the movie Juno, the ultra sound imaging technician lauds Juno, the pregnant teenager, for putting her child up for adoption because the technician has seen too many cases of disturbing teenage mothers raising children in the worst possible way. Well who is to say that the adoptee’s parents would be better suited? The presumptuous technician then received a mouthful from Juno’s step mom.

Other factors include age, gender, social class, and ethnicity of the provider in the eyes of the client and of the client in the eyes of the provider.

So consider how accessible your provider is and shop around for the provider that best suits you and vice versa.

Sponsored by George Mason University, the College of Health and Human Services Center for Health Policy Research and Ethics, the Washington Health Policy Institute hosts its 16th annual meeting from June 3rd through 6th of 2008.At the meeting, “academics and health professionals interested in health policy research can learn firsthand about current policy issues and how policy is made through lectures and discussion with some of the nation’s leading policy makers. Students can also earn graduate credit through the Institute by attending morning didactic sessions and completing an analytic policy paper. An additional Institute option is the Policy Leadership Training Program for post-baccalaureate students and health professionals with a desire to enhance leadership capacity and skills in policymaking, research, and advocacy.”

Here’s a list of invited speakers –

BILL FINERFROCK
Vice President, Health Policy
Capitol Associates Inc.PATRICK FINNERTY
Director, Virginia Department
of Medical Assistance Services

PAULA HOLLINGER, RN
Associate Director, Health Workforce
Maryland Department of Health and
Mental Hygiene, and Former Senator,
Maryland General Assembly

DIANA MASON, PhD, RN, FAAN
Editor in Chief, American Journal of Nursing

ERIN McKEON
Associate Director, Government Affairs
American Nurses Association

ALAN MORGAN, MPA
Executive Director
National Rural Health Association

FRANK PURCELL
Director, Federal Government Affairs
American Association of Nurse Anesthetists

CATHY RICK, RN, CNAA, FACHE
Chief Nursing Offi cer
Veterans Health Administration

ALLISON WEBER SHUREN, MSN, JD
Arent Fox Kintner Plotkin & Kahn, PLLC

PEGEEN TOWNSEND, JD
Senior Vice President, Legislative Policy
Maryland Hospital Association

Since this meeting is slanted towards eligible graduate credit or CEU’s, I encourage students and policy practitioners with a few days in Washington D.C. to spare to attend.

After this affair, you may piggy back off the 25th annual AcademyHealth Annual Research Meeting, which follows soon after George Mason University’s affair.

“HEAR US NOW!
RAISING WOMEN’S VOICES FOR THE HEALTH CARE WE NEED!

Thursday & Friday, April 17 and 18, 2008
Hosted by: Simmons College
Boston, Massachusetts

Featured Keynote Speakers
Dr. Joycelyn Elders, Former Surgeon General
Miriam Yeung, National Asian Pacific American Women’s Forum
Byllye Avery, Avery Institute for Social Change, Black Women’s Health Imperative

Join us and more than 300 other activists, mothers, daughters, sisters, caretakers, consumers and community leaders for this national conference to learn and strategize about how we can get quality, affordable health care for all. Together we will discuss and plan for health care reform that will meet the needs of women and families.

This conference will launch a network of trained and outspoken women who are mobilized to work for a health care system that:

• Includes comprehensive reproductive health services
• Meets the needs of diverse women and our families
• Bridges the inexcusable gaps in services and care that we face in the current system
• Provides quality health care that is affordable and accessible for women and our families across the life-span.

To get the health care debate to reflect women’s issues and concerns, we must join the conversation!

REGISTER by March 12 FOR EARLY BIRD REGISTRATION RATES!
Questions? 866-210-3114

Did you consider whether or not you qualify for public programs?

Medicaid is generally for low-income individuals and families with specific health condition(s) or family arrangement. Or Medicare is generally for 65+, some disabled, or all end stage renal disease persons.

In progressive locales, governments may have local health coverage for its residents. In San Francisco, Healthy San Francisco offers basic health needs to all residents by formalizing the fragmented safety net care.

If the aforementioned are not applicable and no insurance is out of the question, then shop for an individual health insurance plan.

Since the individual health insurance market is unregulated, comparison shopping sites like ehealthinsurance.com has not changed much in the last decade. I highly recommend researching health care benefits and receiving comparison quotes from this easy-to-use site. It offers well-known carrier options, applicable by locale: Aetna, Blue Cross, Health Net, Humana, Blue Shield, Kaiser Permanente, UnitedHealthcare, and more.

When providing your profile, have the following information handy:

• Gender (Premiums are often banded by gender. Women have different needs than men, biologically speaking)
• Birthday (Premiums are often banded by age groups. A 60 year old’s premium and costs will be much higher than a 30 year old’s)
• Tobacco usage in the last 12 months (Kick that smoking habit already!)
• Zip code (Not all large insurance companies have offerings in each locale. i.e. Kaiser Permanente)
• Date of coverage to begin (Try to pick the beginning or the 15^th of the month, which are easy to remember dates.)

Then presto, a list of health plans with monthly premium, plan type (HMO, PPO, or POS), deductible amount, coinsurance level, and office visit cost are quickly displayed. You can research more about the plans in regards to user reviews, benefit details, and physician network.

The user reviews are fairly weak considering there is no way to follow-up with the user to elaborate on experiences. Since the plans offered are from nationally recognizable health plans, you can ask a friend with coverage from the same company.

Next up, researching a health plan for a friend.

After a company buy-out, my friend decided to take company severance and work as an independent contractor. The freedom and liberty to go as he please comes at a price, one being affordable health insurance.

Before delving into the individual health care market, first read Insure.com’s tips for buying individual health insurance.

Then, consider if these options are viable:

Spousal coverage
If your spouse is employed and has group health insurance, have him or her extend insurance to you.

No spouse, then no consideration. Rarely have I heard of marriages for health insurance, well except for U.S. citizens with Canadian citizens getting a piece of across the border health care. That is not likely to happen if you can not and do not frequent Canada.

COBRA coverage
Within a 63-day period, if your company is required to extend your current health insurance upon your departure, you can pay the full premium to maintain the same coverage. Depending on how lenient your company is, you may forgo the additional 2% administrative cost. In total, you pay up to 100%-102% of the full premium. You can be insured up to 18 continuous months. After that time period, if you are still in the individual health insurance market, then you are back to square one.

In the case of those who have been independent contractors for some time, COBRA coverage does not apply.

Group coverage through associations
Individual health insurance is priced differently from group insurance that one receives through employers, and oftentimes, the pricing can be much higher for the un-savvy shopper. Look for insurance offers from your alumni club or trade organizations, which sometimes, but rarely, have premiums set at group insurance levels.

If none of these apply, then read the next entry on selecting a health insurance plan suitable for you, the independent employee working for the company of one.

The creme de le creme health care policy research meeting returns with a big bang, celebrating its quarter century anniversary!

Registration for Academy Health’s 25th Annual Research Meeting (ARM) begins tomorrow, Friday, February 15th. This milestone event will be held at headquarters in Washington, D.C. during June 8-10. Early birds can save $100 prior to April 7th registration.

Not a member? No worries, membership purchase in itself pays for registration and will not cost you a penny more when compared to existing members. Registration fees are tiered by individual, organization affiliate, speaker, fellow, and student. Daily passes are also available.

The preliminary agenda is likely to evolve in the next few months, and quarter century anniversaries are likely to attract a respectable powerhouse of policymakers, researchers, and upcoming movers and shakers.

Plan on arriving/staying a day or two prior to/after the event to meet with interest groups. Meetings announced thus far:

Meeting on Saturday June 7th
Child Health Services
Interdisciplinary Research Group on Nursing Issues
Public Health Systems Research
State Health Research and Policy

Meeting on Tuesday June 10th
Disability Research

See you there!

Deadline for Academy Health’s 2008-2009 Health Policy Fellowship will creep up on you right after the holidays. So mark your calenders and apply!

January 7, 2008
Deadline for proposal submission
April 1, 2008
Announcement of selected a junior and senior level fellow
Early September 2008
Commencement of fellowships

Essential criteria for application
- Pry analysis and conclusions based on the National Center for Health Statistics (NCHS) data sets.
- Propose relevance and usefulness to health policy or health service research (of course!)

Here is a photo list and associated credentials of past fellows. Guess who is the junior and who is the senior. Their project sound interesting

2002
To Examine How the Effects of Managed Care Market Penetration on Nurse Staffing in Hospitals Affect AMI Patient Mortality

2003
Organizational Determinants of Disparities in Hospital Care
Firms’ Demand for Health Benefit Generosity

2004
Effects of the State Children’s Health Insurance Program (SCHIP) on Children’s Health Insurance Coverage, Access to and Utilization of Health Services, and Health Outcomes

2005
Estimating the Effects of Health Insurance on Quality Adjusted Life Years
Depression Symptoms, Poverty, and Single-Parenthood: Effects of Maternal Factors on Children’s Use of Preventive Health Services

2006
Recipients of Work Disability: Who, When, and For How Long?
Trends of Integrating Clinical Preventive Services Into Primary Care

2007
Functional Decline Among the Elderly: The Impact of the 1997 Balanced Budget Act
Hospital Admissions from the Emergency Department: National Trends and Variation Between Hospitals

Good luck!

Just received my Robert Wood Johnson Foundation Anthology To Improve Health and Health Care, Volume XI. The website for the book is not even up yet, but here are the past volumes:

After 2001, the foundation changed the associated years to volumes. Perhaps because with each year, there is marginal improvement in health and health care that all the ideas begin to sound the same from year to year. A volume label will help readers understand that there really has not been a monumental change. Because of the health care beast, inching improvements are subtle and easily awash with a slightly bigger issue, like the war. The illustrations all portray a look of somber wishful thinking and hopeful future outlook but with a big * sigh *. So I hope to read the most recent volume and be caught up with the last few volumes.