What more can we do?

“I don’t understand how children who are living poverty, who have nothing but the sandals that are three sizes too small on their feet, a T-shirt full of holes, and the three pieces of candy that they will try to sell on the street later that night for money, smile all day long. It doesn’t make sense how two siblings whose parents have both died from AIDS, who don’t have a place to go home at night, have the strength to hold each other’s hands and walk down the dirt road after school is over for the day. It blows my mind to watch 96 children who haven’t eaten for over 24 hours be so patient as to help the youngest children get their meal for the day before they get their own.” -Lindsay Cottrell, MHSA Candidate 2009; Assistant Direct of The Olevolos Project

Quote from Ah-Ha! in FINDINGS, Volume 23, Number 1 Fall/Winter 2007, a University of Michigan School of Public Health publication

 So what are you whining about in life? Channel that energy into projects that eliminate sad quotes and create a balance between the selfless and the selfish.

Shake Down in Organization Management

Scenario A

“There’s only one reason why we work here.”
“What’s that?” I said, the perfect nerdy straight man.
“The paycheck,” he said, and walked away.

“What I learned that conformity was highly prized, appearance was more important than substance, and managers always stayed till 5:05.” - University of Michigan Health Management and Policy Professor John Griffith’s experience in management published in  Ah-Ha! in FINDINGS, Volume 23, Number 1 Fall/Winter 2007, a University of Michigan School of Public Health publication

Scenario B

Prestige was measured “by how few people there were above you who could prevent you from doing what you wanted to do.”

“The all-hands open-book session. Customer logs, revenue flow, fraud losses, burn rate; He’d display it all for every employee to see. This access to information coupled with the lack of offices, created a flat structure where any idea could win the day.”

“You didn’t measure where you were in the organization by how many people you’re managing.” he says. -Peter Thiel of the PayPal Mafia

Commentary 
The health care system is burdened by too many wage earners under scenario A. It’s time to cut the real losses, human resources that use their employment to sustain their own life and none others, to stroke their own egos at the expense of their peons, and to only think of today instead of living to learn, excel, and change. It is time to shake down people’s attitudes and hire people with compassion, competence, and competitive spirit in the health care industry. Let’s challenge people’s stodgy notions, starting from the education system.

Photo Credits: Peter Thiel from Singularity Institute for Artificial Intelligence and Professor John Griffith from the University of Michigan, School of Public Health, Health Management and Policy

Retro Actively Ineligible for Insurance

 versus

California Insurance Commissioner Steve Poizner is slapping California Blue Shield on the back of their hand with a $12.6 million fine. Surely, this figure would not even rustle the feathers of many tech start ups, but when the 2004 average health care expense per capita in California was $4,638, this fine may cover the annual health care bill of about 2,700 persons.

Recall in Sicko when this insured lady had gone through medical treatment, and a few weeks later her health insurance company retro actively cancelled her insurance coverage. She was left with thousands of dollars in medical bills, which she thought she only had to pay a reasonable co-insurance or copay for. Her insurance company yanked her coverage because of lack of full medical history disclosure. Of a yeast infection, specifically. It was completely unrelated to her medical treatment. Who knew a treatable and fairly common infection could pull a startling surprise and pummel another American into deeper and insurmountable financial debt.

Health insurance companies claim that by leaving out any miniscule detail of one’s medical history is a path to coverage fraud. Surely, medical history disclosure at the time of application is the common commercial insurance practice to keep away people already known to seek expensive treatments. The incentive to make profit off of premiums is to not pay out claim expenses. Insurance companies rely on the applicant to list all previously diagnosed illnesses, common, severe, and even cured from. Then the company begins cherry-picking their applicants only to admit the healthiest applicants.

(You know you are guilty of cherry picking too. You pick the shiniest, reddest, and plumpest cherry. Oh this rule applies to lemons and apples too. Your entire grocery trip in fact.)

With all the administrative hoops to prove one’s identity in order to get indecipherable medical records in person, people often rely on their fallible memories to collect an entire medical history to apply for insurance. Most people do not have the intention of bilking insurance companies of coverage fraud.

How often will a woman recall her yeast infection from her wild, sexy, and roaring twenties? Yeast infections are so common that self-diagnosis and over-the-counter medicine will prevent mars on perfect medical histories.

The incentives appear to reward the healthiest, the sickest that never seek professional diagnosis and treatment, or the smart evasive ones that get cures from over-the-counter drugs or from a doctor friend with a loose prescription pad. Truly sick, indeed.

 In case you are curious of the 2004 per capita health care expense ranked by State:

United States—–$  5,283

1     Utah—–$  3,972
2     Arizona—–$  4,103
3     Idaho—–$  4,444
4     New Mexico—–$  4,471
5     Nevada—–$  4,569
6     Georgia—–$  4,600
7     Texas—–$  4,601
8     California—–$  4,638
9     Colorado—–$  4,717
10   Virginia—–$  4,822
11   Arkansas—–$  4,863
12   Oregon—–$  4,880
13   Oklahoma—–$  4,917
14   Hawaii—–$  4,941
15   Louisiana—–$  5,040
16   Michigan—–$  5,058
17   Mississippi—–$  5,059
18   Montana—–$  5,080
19   Washington—–$  5,092
20   South Carolina—–$  5,114
21   Alabama—–$  5,135
22   North Carolina—–$  5,191
23   Wyoming—–$  5,265
24   Illinois—–$  5,293
25   Indiana—–$  5,295
26   South Dakota—–$  5,327
27   Iowa—–$  5,380
28   Kansas—–$  5,382
29   New Hampshire $5,432
30   Missouri—–$  5,444
31   Tennessee—–$  5,464
32   Kentucky—–$  5,473
33   Florida—–$  5,483
34   Maryland—–$  5,590
35   Nebraska—–$  5,599
36   Wisconsin—–$  5,670
37   Ohio—–$  5,725
38   Minnesota—–$  5,795
39   New Jersey—–$  5,807
40   North Dakota—–$  5,808
41   Pennsylvania—–$  5,933
42   West Virginia—–$  5,954
43   Vermont—–$  6,069
44   Rhode Island—–$  6,193
45   Delaware—–$  6,306
46   Connecticut—–$  6,344
47   Alaska—–$  6,450
48   New York—–$  6,535
49 Maine—–$  6,540
50 Massachusetts—–$  6,683
51 District of Columbia—–$8,295

Health Care Revolution

Wow, I have been MIA for several months. Yet when I read the California Health Line, Kaiser Family Foundation report, or San Francisco Chronicle health care articles, the issues are still the same ones discussed from months prior. No additional Federal funding for the Children’s Insurance Program, growing numbers of the uninsured, lack of comprehensive coverage for the uninsured, improper incentives for managed care companies, lack of physician accountability, the D in Medicare Part D stands for donut hole disaster, and the list drones on and on.

These are the same issues we faced 5 years ago. How are we going to move forward in health care? Unfortunately the health care beast is not agile, is inflexible, and is tumbling down a narrow tunnel of thought, deeply rooted in antiquated processes, and plagued with technological costs and capital investments that have not become sunk.

How discouraging. Even the optimistic and savvy Esther Dyson puts out her technological passion for making a difference in our lives no matter in what kind of bull or bear economy, but her Huffington Post blog on Health2.1 — Afterthoughts on the Wonderful Health 2.0 Conference was ferociously attacked.

How discouraging. The bright eyed bushy tail Health Management and Policy graduate is jaded by our health care system. And that is the reason for my lack of updates.

What is encouraging is the feeling ones gets from awakening from the discouraged funk. What does not kill you with words or sticks and stones can only make you stronger. I have an idea to revolutionize the health care system. I just need to bounce it off the right people that do the right thing at the right time and have the energy to do so. Although, I do need reality checks, please do so in the most constructive manner. I will soon share…

Down to personal health

Earlier this month, I received my annual exam results, and I had one stunner. I have high cholesterol that shot past the normal total blood cholesterol level.

209 mg/dL

108 from HDL (good, >40-50)
92 from LDL (bad, <130)

Remember that ad back in the 90s. This slim and bodacious gal in her little black dress flings the limo door open. She proceeds to strut down the red carpet as the paparazzi camera flashes go on a blitz. The gal then trips and falls because even though she looks thin, her cholesterol is off the charts. I am a poster child for that ad’s cause.

So for this past week, I took my diet one step further and decided to cut out all dairy, cheeses, and butter. I realized how little sensitivity restaurant foods have for the lactose intolerant. Just evening ordering a crepe made me cringe. Nothing on the crepe menu is without cheese. So take that cholesterol.

Instead of eating out, I am doing a 180 and being more hands with foods that goes into my body. Salads twice a day, 7 days a week is just not that appetizing. I must cook and make wise selections.

I dread this because who has the energy to cook after a 12 hours day at work? Let’s see how this experiment goes. And let’s see how self-cooking will impact my pocket book in exchange for health.

Let the tongs clang!!!!!!!!!!

Ranking of U.S. States + D.C. Health Care System Performance

Blah! I am a month late!

The Commonwealth Fund released a ranking of all fifty U.S. States and the District of Columbia (D.C.) on how the states rank in terms of their health care system. Not surprisingly since Hawaii eked by with an employer mandate, the state ranks #1. After the number one spot, the true #1 spot which is the #2 spot is fair game to those who have to abide under the Federal Employment Retirement Income Security Act (ERISA).

Results from a State Scorecard on Health System Performance
1 Hawaii
2 Iowa
3 New Hampshire
4 Vermont
5 Maine
6 Rhode Island
7 Connecticut
8 Massachusetts
9 Wisconsin
10 South Dakota
11 Minnesota
12 Nebraska
13 North Dakota
14 Delaware
15 Pennsylvania
16 Michigan
17 Montana
17 Washington
19 Maryland
20 Kansas
21 Wyoming
22 Kansas
22 New York
24 Ohio
24 Utah
26 Alaska
26 Arizona
26 New Jersey
29 Virginia
30 Idaho
30 North Carolina
32 District of Columbia
33 South Carolina
34 Oregon
35 New Mexico
36 Illinois
37 Missouri
38 Indiana
39 California
40 Tennessee
41 Alabama
42 Georgia
43 Florida
44 West Virginia
45 Kentucky
46 Louisiana
46 Nevada
48 Arkansas
49 Texas
50 Mississippi
50 Oklahoma

The authors documented 32 indicators lumped into 5 performance categories: access, quality, avoidable hospital use & costs, equity, and health lives.

I am immensely disappointed that California is in the same bottom quartile as Texas. For access, quality, and equity California is in the low quartiles. But for healthy lives, the State is in the top quartile. There are just a disproportionate number of healthy people and unhealthy people in the state that skews these rankings. I would focus on access, quality, and equity wherein lies the people who truly need health care.

Sick to Sicko

What a great segue from Sick to Sicko. Upon Sicko’s release, I refrained from immediately offering comments. I tend to heavily regurgitate what I see into what I write; and so the slight delay was to prevent spoiling your viewing pleasure. You have been forewarned.

To fend off any reactionaries: absolutely, Michael Moore did not give a holistic view of the fragmented health care system. However, just as an element of truth lies within each joke, the most egregious health care issues precipitate from documentary exaggeration. Not that the viewer should take the movie with the grain of salt, but rather the viewer should see how that grain salt fits into the entire health care ecology.Moore highlights well-documented and debated issue amongst health care professionals in the past decade. He places an emphasis on health maintenance organizations (HMOs) which use an array of cost and utilization control.

HMO tactics such as coinsurance, copays, and deductibles from the cost side and primary care provider referrals, pre-authorizations, and prescription drug formularies from the utilization side are widely recognized “blunt” instruments that have unintended and dire consequences. These instruments lack the precision of helping the purchaser decide whether or not he or she truly requires health care services.

For example, many insurance policies have a copay starting at $50 or at least a 20% coinsurance for emergency room visits that do not proceed with hospital admittance. Reading between the lines, this payment structure tempts the purchaser to evaluate his or her onset of ill symptoms and decide if an emergency visit is warranted. Can the person wait for an appointment? Or will the symptoms ease over time?

Now if a child has flu like symptoms, how does a parent know if he or she can simply drop by the nearby drug store and purchase flu tablets? What if the child has meningitis and requires immediate attention? The latter warrants an ER visit, but the potential out-of-pocket costs leads the parent to think twice.

Why should a parent think twice if a child exhibits unhealthy symptoms of unknown illness? The parent may not be a licensed medical professional to make that judgment, but the insurance company makes a presumption that the purchaser believes the parent can make that choice.

The policy is not sensible.

Well this policy did not stem from insurance companies greed. Before cost and utilization management policies existed, emergency room costs were a large portion of the hospital’s operating expenses and potential profit centers. The easy access to a multitude of ERs led to abuse. Too many people visited for non-emergent and unnecessary services. Impatient people simply wanted a quick fix and could not wait for the next available outpatient appointment. Some people could not determine the difference between emergent, urgent, or non-emergent-urgent symptoms. And some people went for the sake of attention. This is what the out-of-pocket insurance policies were trying to deter. If the medical attention was serious enough, insurance companies thought that purchasers were smart enough to decide between an out-of-pocket fee and the price of life.

Well any decision is affiliated with out-of-pocket costs, warrants someone to think twice. Fifty dollars to treat a sniffle or $50 for this week’s lunch money. Healthcare socioeconomics studies show that some parents pocket the $50 for next week’s tangible and immediate living necessities. If indeed the child had an unsuspecting case of meningitis, the copayment or coinsurance policy created an unintended decision, and the ill-decision may directly lead to irreparable brain damage for the child.

The insurance company then prevents from paying out $1,000+ for the ER visit and now may have to fork over more money to treat brain damage. With the existence of Sicko anecdotes on denial of treatment, the possible vicious cycle of denials may ensue for the child’s treatment.

As long as anecdotal stories like this exist, our health care system is sick. What Sicko does not point out is the shift from HMOs to PPOs and other insurance mechanisms. Unfortunately, Moore brings up issues that persistent even in the back shift from HMOs to Point-of-Service (POS) plans and Preferred Provider Organizations (PPOs). Fortunately insurance companies under the POS plan and PPO operations are shifting attitudes and practice, which Moore did not even highlight. Unfortunately, the shift is too slow for consumers to notice.

In addition, there was no mention of nearly universal health care coverage in Hawaii, the single state that mandated employers to offer health care coverage since 1974. Hawaii was the only State that narrowly escaped from the Federal government’s Employee Retirement Income Security Act (ERISA) also passed in 1974. Although Hawaii’s Prepaid Health Care Act mandates employers to offer health care coverage for employees that work more than 20 hours a week for at least four consecutive weeks, this is a tremendous stride for small companies and mom and pop stores to be able to set their commercial prices in order to offer coverage for their vulnerable employees. Hawaii would be a great documentary case study of a state with high health insurance coverage and health care access. California and Massachusetts are moving towards that direction, with risks of violating ERISA.

Hate the current system? Then form a health insurance coalition with policy driven by sound medical advice and peer review. Why wait for the government to form a single payer system? By the way, the single payer system is a non salient term to push health care burden onto the government. If policy makers require buy-in, stay away from mentioning single payer system. Just coin another catchy term. Otherwise, the words single-payer-system will be instant death on any politician’s or policy maker’s career.

Despite the lopsided view, Sicko does end with a beauty in living a society of “we” instead of “me.” The health care industry needs to hire talent with a strong sense of compassion for others. And there needs to be an impetus to re-prioritize our values.

Jonathan Cohn’s The Untold Story of America’s Health Care Crisis and the People Who Pay the Price

Browsing through my inbox, for whatever reason, Steve Heilig of the San Francisco Medical Society has my work email and spammed my inbox with his San Francisco Chronicle book review of The Untold Story of America’s Health Care Crisis and the People Who Pay the Price by Jonathan Cohn.

Why did I choose to pursue health care policy as a lifetime career? Poignant anecdotes arouse my anger. Steve points out a story on family’s unmet medical are simply due to lack of affordability and how the industry born from compassion employs incompetent people with lack of sensitivity:

“One strength of “Sick” is that Cohn illustrates his factual and historical information with real-life stories, albeit invariably sad ones. There are far too many from which to choose, but consider Steven and Elizabeth Hilsabeck of Texas, whose son was born with cerebral palsy; physical therapy is indicated to help people with this incurable condition, but the family’s “managed care” insurers suddenly stop paying for it. A clerk informs them wrongly that they are only covered for 60 visits per lifetime; and then asks them, idiotically, “When is he getting over the cerebral palsy?” The couple considers divorce just so Elizabeth might become poor enough to qualify for Medicaid. Instead, they sell their home and move into a cramped trailer to afford care for their kids. Other unfortunate people profiled here wind up in other trailers, and some of their lives end with suicide, brought on by the despair of never getting the care they need.”

How can people work in the health care industry, regardless of what medical or business role, and ask when a person will get over cerebral palsy. Health care is inefficient due to the lack of passion, innovation, and forethought from ignorant people occupying health care jobs. I wonder how much the nation pays for putting the wrong people in these health care positions. What proportion of these inefficient costs drives the unaffordable prices?

Changing Environment for Health Care Services and Coverage

The erosion of entitlement thinking

“Health care is not free. It is a scarce social resource that should be cherished and used sparingly when most needed. Personal responsibility should play a part.”

James Robinson, Ph.D., M.P.H.
University of California at Berkeley, School of Public Health

AcademyHealth 24th Annual Research Meeting

I am kicking off this blog live from AcademyHealth’s 24th Annual Research Meeting in sunny Orlando, FL. The meeting is actually in Lake Buena Vista in the all-inclusive resort town of DisneyWorld. There are a fair share of interesting and provocative speakers as there are soporific lectures. I will blog about the salient issues that are on the bleeding edge of health care financial policy.

Personally I am looking forward to the following speakers and panelists:

David Cutler, Harvard University
Keynote address on New Approaches to Health Care Reform
Paul Ginsburg, Ph.D. Center for Studying Health System Change
Panel Chair
John Hsu, M.D., M.B.A., M.S.C.E., Kaiser Division of Research, Kaiser Institute for Health Policy, University of California at San Francisco
2007 Article of the Year Awardee for Unintended Consequences of Caps on Medicare Drug Benefits”
Mark V. Pauly, Ph.D., Wharton School of the University of Pennsylvania
2007 Distinguished Investigator Awardee
James Robinson, Ph.D., M.P.H., University of California, Berkeley
Panelist
Kevin Volpp, M.D., Ph.D., Center for Health Equity Research and Promotion at the Philadelphia Veteran Affairs Medical Center and University of Pennsylvania
2007 Alice S. Hersh New Investigator Awardee

Marked session topics of interest:

SCHIP Reauthorization: Moving Forward, Standing Still or Sliding Back?
Ten+ Years of Tracking Health System Change: What Does It Tell Us About the Potential for Markets in Health Care?
CMS Research Update
Use of State Level Research for State Initiatives to Expand Coverage
Medicaid Coverage, Policies & Performance
Improving Health & the Use of Medical Services: Analyzing the Contributions of Medicaid & SCHIP
Powerful Data, Meaningful Answers: An Introduction to the Healthcare Cost and Utilization Project (HCUP)
Public Policy & Health Care Markets: Intended & Unintended Effects
Best Papers & Article-of-the-Year
Politics & Policymaking in State Coverage Expansion Efforts, 2007: Challenges & Opportunities