Health Politics

During one of our recent events, Sheldon Garon of Princeton University and Ray Boshara of the Federal Reserve Bank of St. Louis referred to the weak household balance sheet as one of the core economic challenges of our time, suggesting that households must focus on asset-building rather than rely on credit and debt.

The folks downstairs at the Committee for a Responsible Federal Budget clued us in last week to an ongoing debate they've been having with the Center on Budget and Policy Priorities. The central piece of the debate is CRFB board member Erskine Bowles's recommendations to the Supercommittee, which included about $600 billion in reduced Medicare and Medicaid spending. The posts are interesting throughout, and as the deadline approaches, we felt it was important to check in on the federal budget side of health policy.

Here's the debate, with a our commentary:

The initial post: Bowles Plan Offers Path to Compromise

The most important aspect of Bowles' plan, from our perspective, is the method proposed by the Fiscal Commission for fixing the Sustainable Growth Rate (the ironically unsustainable Medicare reimbursement cuts that Congress pushes back each year). In order to pay for a long-term "doc fix" (which would bring down spending on physician fees by cutting rates of reimbursement), the commission recommended that Medicare "develop an improved physician payment formula that encourages care coordination across multiple providers and settings, and pays doctors based on quality instead of quantity of services."

This recommendation is critical. Moving away from the current fee-for-service system is among the most important ways to change how doctors make decisions; at a bare minimum, the Supercommittee should recommend changing reimbursements to reflect the value of primary care instead of encouraging the overcapacity of specialists we have right now.

CRFB didn't specifically mention it, but another critical Medicare fix that the Fiscal Commission recommended is removing the hospital exemption from IPAB recommendations. Given that hospitals make up a huge amount of our total medical spending and are the setting for a huge amount of unnecessary treatment, it's crucial that IPAB have the authority to recommend changes that improve hospitals' incentives to treat patients efficiently.

Related to the initial post: Actually, Raising the Medicare Age Is Also A Good Idea

CRFB's discussion of raising the Medicare age from 65 to 67 is the primary inspiration for this post's second title: we just can't find any good reason to support it.  (If you're really interested in why, we recommend The Incidental Economist's podcast on the subject.)

The thing is, we agree with CRFB on the facts surrounding the issue. Raising the Medicare age would decrease federal health spending somewhat. (The CBO numbers they mention are higher than the ones cited by Carroll and Frakt in the podcast, but not unreasonably so.) On the other hand, they also acknowledge that the shift would increase costs in the private market beyond the savings to the government (because Medicare pays lower reimbursement rates than private insurance). We at New Health Dialogue are concerned with the high total level of spending on health care, rather than simply the level of federal spending on health care. Unnecessarily increasing total medical spending therefore seems like a high cost to pay for a slight reduction in the federal budget which would probably be shortlived, since many of those 65-67 year olds would need help getting insurance, probably through the exchanges specificed in the ACA.

CBPP's initial response: Bowles “Compromise” Proposal to the Right of Boehner Offer to Obama in July

We have to point out a framing problem in CBPP's analysis: not all Medicare and Medicaid cuts are created equal. Some cuts (like those generated by raising the Medicare age) are simply shifting costs from the federal budget to beneficiaries. Those can be fairly labeled as "cuts," and they do increase the burden of health care spending on the elderly. Some of the $600 billion in lower Medicare/Medicaid spending, though, is intended to come from eliminating overtreatment and waste in the medical system. We're well aware that "eliminating waste, fraud, and abuse" is usually what politicians say they'll do to pay for things that they have no intention of actually paying for. However, the Dartmouth Atlas and other analyses have demonstrated that health care really does have a huge amount of wasteful care. Deciding to give patients only the medical care they need, rather than whatever local practice patterns dictate, deserves to be called what it is: responsible management of taxpayer dollars (and of the health system more generally). Demagoguing against such cuts because they reduce health entitlement spending ignores the possibility of making the health system work better, and stands in the way of real progress.

Maggie Mahar, over at the Health Beat Blog, has a great idea:

The US Preventive Services Task Force should be independently funded by drugmakers, medical device manufacturers, and other players in the medical industry - not subject to the Congressional appropriations process.

There's a clear reason why: as we've documented in earlier posts, the Task Force has been subject to political backlash before, and Congress has taken out its anger on health agencies' budgets before. There's ample precedent for independent funding of similar groups, as well. Mahar points to the Financial Accounting Standards Board, which is funded by all public companies (which are required by law to contribute). The Federal Deposit Insurance Corporation's insurance fund is similarly drawn from FDIC-insured banks. Those organizations provide a service to the entire financial system, and their functions would be significantly impaired if they had to constantly worry about irking some Member of Congress by making a policy that harmed a major local business.

Clearly, it's time to take the future of preventive medicine out of Congressional hands. Leave science to the scientists.

We've been expecting this news for a while: organized urology has fired up its PR message machine to attack the recent USPSTF recommendation against routine PSA testing. Not surprisingly, the message's intent is to scare patients into calling their Congressmen to complain.

Here are a couple of the "Action Alerts:" 

From the American Association of Clinical Urologists...

Here’s a list of the recent fibs, misdirections, misstatements and outright lies uttered by a wide variety of opinionmongers in reaction to the new guidelines on prostate cancer screening with the PSA test issued by the U.S. Preventive Services Task Force.

CLAIM 1:

“There weren’t any urologists on the task force!” This was uttered by none other than Newt Gingrich, former Speaker of the House and now-presidential candidate, during the Republican debate at Dartmouth College this week. The charge was also leveled by Dr. Patrick Walsh, University Distinguished Professor of Urology at Johns Hopkins Medical Institutions. (Walsh also pioneered “nerve sparing surgery,” a technique for removing the prostate that helps preserve a man’s ability to get an erection.)

They’re right: there were no urologists on the task force. Instead, there were 15 experts, all of whom have advanced degrees in addition to their medical training, and the statistical knowledge to parse medical evidence. You don’t need to be a urologist to dissect a scientific study, and there are plenty of urologists out there who wouldn’t know the first thing about doing so.

Perhaps Paul Goldberg, publisher of The Cancer Letter, said it best when describing the urologist Gingrich cited: “I wouldn’t call him an expert in prevention; I would call him a urologist.”

Whenever a deeply held belief comes into conflict with evidence, the stage is set for the sort of pitched battle we’re now seeing over the U.S. Preventive Services Task Force (USPSTF) guidelines for prostate cancer screening. We’ve got headlines proclaiming “Men Can't Afford to Skip the PSA Test,” letters to Congress saying “the U.S. Government is putting the lives of thousands at risk,” and a doctor telling the New York Times, “We will not allow patients to die, which is what will happen if this recommendation is accepted.”

The reality? The report (full version here) says that there is “moderate or high certainty that [routine PSA testing] has no net benefit or that the harms outweigh the benefits,” and thus gives it a “D” rating. “D,” in this case, means “discourage this service.”

Note what the recommendation doesn’t say. It never tells doctors to “deny this service.” Nor does it say to insurers, “don’t pay for this service.” The USPSTF does not ration care, determine what private insurance has to cover, or even determine what Medicare will pay for.* Rather, the task force’s sole purpose is to distill research findings into concise advisory opinions for medical providers.

The effect of all the fearmongering -- in addition to misinforming men about the potential risks and benefits of the PSA test – is to set the stage for some potentially dangerous political theater. Congress has a habit of threatening research agencies when their findings displease some important constituency. The last controversial recommendation from the USPSTF (which said there was no need for women ages 40-49 to have annual mammograms) generated such fallout that the current recommendation was held back for nearly two years – depriving men and their doctors of crucial information about the risks of getting a prostate screening test.

It was pretty hot last week, but the mercury has just kept on rising. Rising even higher has been the quality of work in the health policy community. This week, Joe Padua at Managed Care Matters highlights some of the finest health wonkery this side of the Congressional recess.

If you (like us) are stuck in swampland while our incredibly effective elected policitical leaders skip town for a month, prepare yourself for the fall's rough and tumble health reform fights with the work of this week's Health Wonk Review!

Many aspects of health care reform require revolutionary thinking and groundbreaking research to move the system down unexplored pathways to new heights of efficiency and excellence.

...And some things don't. There are some solutions we see clearly right in front of our noses, with their implementation stymied by perpetual politicing. If you ever needed a clearer pictures of how our current Congressional process is ill suited to actually controlling the ever increasing costs of Medicare (and why IPAB, despite all the hemming and hawing on the Hill, is desperately needed), look no further than Sam Baker's report today in The Hill:

A bipartisan majority of House lawmakers is pressing Medicare to reverse a proposed cut to hospital payments.

The Medicare agency recently proposed a 3.5 percent cut in payments to hospitals as well as a 2.9 percent adjustment to offset payments that it said are the result of changes in how come claims are filed. But 219 House members said hospitals can't afford the cuts, and urged Medicare to reconsider the proposal.

"If the proposed rule is enacted, the net impact for hospitals would be an average decrease in inpatient payments," the lawmakers said in a letter to Medicare Administrator Don Berwick. "This is a decrease that hospitals can ill afford."

The letter says hospitals could lose more than $6 billion from the proposal. It was signed by 95 Republicans and 124 Democrats. A similar letter in the Senate garnered 45 signatures.

If we actually want the government to spend less on health care, we need to actually spend less on health care. And yes, this means somebody WILL make less money. Today's unacceptably high levels of Medicare spending will always be somebody else's acceptably high levels of Medicare income. It's the inability to contemplate short term "belt tightening" and shared sacrifice, at the expense of the long term sustainability of the health care system as a whole, that turns today's symptoms into the combined fiscal-healthcare crisis (and graph) everyone predicts.

Here we go again. It’s time for the next skirmish in the mammography wars, sparked this week by the American College of Obstetrics and Gynecology’s new recommendation that women in their 40s get annual mammograms. The usual suspects have come out in droves, cheering the recommendations as a “victory for women’s health.”

I’m not going to get into the weeds of why this new recommendation is an example of faith-based (as opposed to evidence-based) medicine, but here’s a thought experiment: If yearly mammograms are a good idea, wouldn’t getting one every six months be even better? The idea behind yearly screening is to detect cancer early. Catch it before it causes symptoms and it’s curable. Let it sit around, growing undetected, and you’re more likely to die an early death. 

If that’s so, why not screen more frequently, say, every six months? I mean, if every woman in America over the age of 40 got a mammogram every year for the rest of her life, many would still die from breast cancer. The obvious solution here is to screen more often, and to start earlier than age 40.  How about at puberty? Better yet, why not screen women four times a year, or six? Surely bimonthly mammograms are not too high a price to pay for saving women’s lives.

Two days ago, we wrote about the “kerfuffle” surrounding a recent McKinsey & Co. study. The study claims 30% of employers will drop employee health care coverage, contrary to many other non-partisan reports. Despite the study being picked up by most major news outlets and seized on by health care reform opponents, we found a troubling problem with the study’s methodology: it hasn’t been released.

Even though McKinsey’s own Bowen Garrett, the chief economist at their Center for U.S. Health System Reform, published an Urban Institute report in January that directly refutes the McKinsey study, the aberrant study has continued to be widely cited and circulated.  GOP Senator Ron Johnson and former McCain adviser Douglas Holtz-Eakin are now citing the study as proof of the ballooning costs of Obamacare while Karl Rove opines “The ObamaCare Bad News Continues” in the Wall Street Journal, also pointing to the “devastating” study.

As we said on Wednesday, a study countering common wisdom shouldn’t be discounted out-of-hand, but it certainly warrants a closer look.  Health care policy decisions, much like informed medical decisions, must be based on real and transparent data.

In the days following our blog post, the controversy has been picked up by numerous blogs: