Category Archives: Policy and politics

Health Wonk Review is up at Healthcare Lighthouse

Check out the latest Health Wonk Review blog carnival at Healthcare Lighthouse. This is the TGIR (Thank God It’s Recess) edition when all the health wonks get to ease up a bit with Congress out of session and take a longer term view.

Nonetheless you’ll see some intense posts on health policy.

Take a deep breath: Marijuana product placement is on the way

Coming soon

Coming soon

Paid product placements for cigarettes are back on the big screen. The tobacco industry agreed in 1998 not to pay for product placement in movies. But electronic cigarettes weren’t around then and aren’t included in the ban. Some brands are now pushing the envelope, according to the Wall Street Journal:

Throughout the movie [Cymbeline], actress Milla Jovovich puffs away on an e-cigarette called a SmokeStik. In one scene, signs for the brand hang in a convenience store next to condoms and calling cards.

The product’s cameo appearance comes courtesy of Canada-based SmokeStik International Inc.—in just the kind of paid-product placement that has been off-limits to traditional tobacco companies in Hollywood for nearly two decades.

The cynicism of the cigarette (or nicotine) business is on full display:

“I don’t see a problem with glamorizing something that saves lives,” says SmokeStik’s chief executive, Bill Marangos. Like others in his business, he considers e-cigarettes to be a less-harmful alternative to traditional smokes…

Mr. Marangos wouldn’t say how much the company paid for the placements, but he does allow: “They know we pay well.”

This got me thinking, how long until we see paid product placement for recreational marijuana brands? The weed is now legal for recreational use in Colorado and Washington, and it seems a wave is building that will lead to legalization in other states and perhaps nationally. I think it’s a really bad idea for public health, but the tide is moving against me.

Once the business goes mainstream, I expect to see the development of national brands and the pursuit of a vigorous marketing push via whatever means are not declared illegal. Product placement in movies will be a no brainer to get some buzz for the brand and the film. And as with any sort of drug dealing, it’s a lucrative business that can pony up the cash.

It’s quite possible that we’ll see marijuana “edibles” promoted in films rather than smokes. Ironically that could take us back to the early days of product placement in the movies, to the famous Reese’s Pieces placement in ET. Candies for kids once again.

I hope we don’t see dope promoted with paid product placement, but I think we will.

photo credit: Cannabis Culture via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group

Republican dominated states swallowing their pride on Medicaid expansion

Time to swallow it, fellas, and expand Medicaid

Time to swallow it, fellas, and expand Medicaid

Pennsylvania and now Utah are joining other Republican-run states that have decided to say yes to the expansion of Medicaid under the Affordable Care Act after all, after obstinately deciding to say no after the Supreme Court effectively made expansion optional more than two years ago.

It makes perfect sense. As I’ve described repeatedly (see Texas cuts off its nose to spite its face… and On Medicaid expansion, poor states are subsidizing rich ones) refusing Medicaid expansion is self-defeating for a state. With elections coming up in November, some Republican leaders have realized it might be self-defeating for them in a very personal sense!

All of this is treated as news, but fact is it was predictable at the time, and in fact it was predicted right here on the Health Business Blog. The only surprise is that it’s taking this long. I discussed the ruling with Dan Mendelson, CEO of Avalere Health on June 29, 2012, the day after the  Supreme Court’s decision. Here’s how the discussion went:

Williams: So does [the ruling] mean that there will be a hodgepodge with some states doing the expansion and some not, or is it more nuanced than that?

Mendelson: I think in reality most states, or I would even venture a guess that all states will be compelled to take the expansion, because remember that the federal government pays for the entire expansion until 2017 and then thereafter the subsidy rate is around 90%, so you’d really have to be a rogue state to refuse that.

Or put slightly differently, if you’re the governor of the state, how are you going to stand up in front of your electorate and say, ‘I’m not going to cover people near poverty because I’m worried about the out-year liability that we might incur, and therefore I’m going to turn down the federal government’s largesse.’ I think it would be very difficult for a state to do that.

Williams: So essentially the Court was saying that a stick should come out of the hands of the federal government, but the fact that the Affordable Care Act includes pretty significant carrots, it means that from a practical standpoint this is not a lot of change?

Mendelson: That’s right, and that’s how we did the Children’s Health Insurance Program back in ’97 and ’98. There was a generous subsidy that was put on the table and the states decided that they wanted to cover children or that they had to cover children and it wasn’t long before 50 states had adopted that expansion.

And I think that in this case as well, it is quite likely that unless someone really wants to make an unabashed political statement that states will go ahead and cover these folks who are near poverty.

So far the South is solid in its rejection of Medicaid expansion, except for Arkansas. Look for that to change in 2015, even if the GOP takes the Senate.

photo credit: hragv via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group

Health Wonk Review: September 11, 2014

Nothing to be ashamed of

Nothing to be ashamed of

Welcome to the September 11, 2014 edition of the Health Wonk Review. We’ve got a hearty and healthy set of posts from our wonkish community, including submissions on Obamacare, Medicare, performance measurement and power plants.

Medicare anyone?

In The 125 percent solutionHealth Affairs  bloggers including Elliot Fisher suggest using Medicare as the benchmark for all payments to providers.

“If every patient and every insurance company always had the option of paying 125 percent of the Medicare price for any service, we would effectively cap the worst of the price spikes. No longer would the tourist checked out at the ER for heat stroke be clobbered with a sky-high bill. Nor would the uninsured single mother be charged 10 times the best price for her child’s asthma care.”

Meanwhile,Healthcare Lighthouse informs us that CMS is slowly integrating principles of bundled payment into the base fee-for service hospital reimbursement system. The Medicare Services per Beneficiary (MSPB) measure essentially creates a virtual bundled payment episode for every hospital admission.

Healthcare policy experts know that the Resource Based Relative Value Scale Update Committee (RUC) is a big reason why US specialist physicians are overpaid and procedures so richly rewarded. Medicare generally accepts the RUC’s recommendations and commercial payers blindly follow. Yet no journalists seem able to stir up sufficient attention to this secretive group, which has only gotten less independent over time. Health Care Renewal shares the lament with us.

Obamacare: Con and Pro

In a three-part video interview, Curbside Consult Host Harold Pollack talks with conservative health policy wonk and former Romney advisor Avik Roy about his “universal exchange” health reform plan, “Transcending Obamacare.”

InsureBlog never met an Obamacare-causes-new-problems story it didn’t like, and this week’s entry is no exception: Tax forms will be more complex thanks to Obamacare subsidy calculations.

Heading back to school so you can get a good job? Not so fast. John R. Graham says the Affordable Care Act is affecting your odds of getting full time employment.

While well-insured armchair Obamacare opponents talk of transcendence and throw a scare into schoolgoers, Healthbeat explains why 10 million more people will gain insurance coverage in 2015 and why those who have had direct experience with Obamacare are more likely to support it than those who have only read about it.

Medical cost inflation continues to decline, reports Managed Care Matters. That’s good news for those paying the bills and not as good for those raking in the cash (and for health reform opponents who have to work harder on their arguments against Obamacare).

Get fatty

Put down that donut! Workers Comp Insider posts about a recent report on the status of obesity in America from the Trust for America’s Health and The Robert Wood Johnson Foundation. More than a third of adults are obese and more than two-thirds when factoring in “overweight.” Insider also links to various reports on the relationship of obesity to workers comp.

What Would Cigna do?

Wright on Health examines Christian medical cost-sharing plans, which allow people to be exempted from the ACA’s individual mandate to purchase health insurance, but which are themselves not really health insurance—despite looking a lot like it.  How many people enroll in a plan like this without fully understanding what they’re buying, and how little protection they may actually have?

Does spanking work?

Wing of Zock addresses the often unintended consequences of carrot-and-stick performance measures, of which the recent VA scandal is a regrettable example. Performance measurement is especially difficult in pediatrics, but is essential to tracking outcomes. “Problems begin when performance measures cease to become a means to an end, and become an end unto themselves.”

Power to the people

Population Health Blog takes note of the many eerie parallels between the power-utility industry and health care.  Will there be a smokestack casting a shadow on your favorite integrated delivery system? (I’m not holding my breath, but maybe I should)

That’s it for this edition. Thanks for reading!

photo credit: @jbtaylor via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group

Massachusetts Governor’s race: Their views on healthcare

Election day tomorrow

Election day tomorrow

It’s primary election day in Massachusetts tomorrow, and the candidates for Governor are doing their best to attract the attention of voters. Earlier this year I interviewed all nine candidates for Governor –including all five who are on the ballot tomorrow– about healthcare. I compiled the results in a free ebook. (And you don’t need to provide any contact info to download it.)

Healthcare is an important topic, and if it’s a deciding factor for your vote I encourage you to read and/or listen to the podcasts. We covered healthcare cost containment, disparities in hospital pricing, the role of specific state agencies, electronic medical records, expensive drugs for Hepatitis C, and pediatric issues.

Here are a few key takeaways, with links to each candidate’s interview.

First among Democrats:

  • Don Berwick is a firm believer in a single payer system. He’d like to find a way to phase out private insurance and replace it with a government payer. That’s fairly radical even in Massachusetts, but not unprecedented. Vermont is undertaking something similar. Berwick also emphasizes his experience running CMS (Medicare and Medicaid) and ability to lead and motivate a large government workforce.
  • Steve Grossman also believes that the state should play a strong role in healthcare, but he doesn’t go as far as Berwick in advocating a single payer system. Much of Grossman’s experience in healthcare derives from his career in business, and he’s focused on making healthcare more affordable for small businesses, which is a worthy goal.  He wants to see more resources in the system generally, and wants to address healthcare disparities as well as income disparities.
  • Martha Coakley aligns herself with the current administration’s healthcare policies, not surprising since she’s been involved in their development and implementation. She’s a strong supporter of the healthcare cost containment law known as Chapter 224. She also stressed the need to address mental and behavioral health issues and to remove their stigma.

The Republican candidates differ reasonably sharply from Democrats and from each other:

  • Charlie Baker, who previously ran Harvard Pilgrim Healthcare, believes the state has enough existing authority to increase healthcare transparency and accountability. He’d address the issue of availability of Hepatitis C drugs by building on the vaccination strategy he developed in an earlier state government role. He’d also like Massachusetts to be able to opt out of the federal Affordable Care Act, since he believes that it’s messing up state reform in Massachusetts, which is something I’ve come to agree with.
  • Mark Fisher is refreshing for the bluntness of his stances: no to government involvement in general, whether in transparency, support of electronic medical records, or overall healthcare reform. He does make an exception on Hepatitis C, where he says the government has a role in prevention. At the same time, Fisher expresses the classic anti-big business attitude of a Tea Party candidate. In particular he opposes the way health insurers treated him as a small businessman.

The general election will also feature healthcare businessman Evan Falchuk from the United Independent Party and Jeff McCormick, an independent candidate whose investments include healthcare businesses.

photo credit: secretlondon123 via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group


On Medicaid expansion poor states are subsidizing rich ones

Like many states, proud to be a sucker

Like many states, proud to be a sucker

State lotteries result in the voluntary transfer of wealth by the poor to the rich. It seems the Affordable Care Act is having a similar impact.

In Massachusetts, residents of lower income towns like Chelsea spend more than 10 times as much per capita on the lottery as their affluent neighbors in places like Weston. Lottery spending by the poor enables the rich to pay lower taxes.

It never really occurred to Congress that states would refuse to expand Medicaid under the Affordable Care Act. After all, expansion brings billions in new funding to states, benefiting residents and ultimately flowing into the pockets of local physicians and hospitals. But 23 states have rejected Medicaid expansion, stubbornly refusing federal largesse even though their residents continue to pay federal taxes that fund states that have expanded.

Suckers of the South?

Suckers of the South?

Take a look at the map of Medicaid expansion. States with high per capita income like Connecticut, New York, Massachusetts, Minnesota and California are expanding Medicaid. Lower income states like South Carolina, Alabama, Mississippi, Louisiana and Texas are not. Instead their taxpayers are sending billions upon billions of dollars to Washington for redistribution to the higher income states.

On the one hand, I benefit from the foolishness and stubbornness of the non-expanders. On the other, I do feel badly about those individuals –and provider organizations– who are suffering needlessly from lack of Medicaid coverage.

At least people who spend a big chunk of their incomes on the lottery can dream and maybe even win something. The same can’t be said for the suckers in non-expansion states who are foregoing the same federal benefit they are financing for others.

photo credit: DieselDemon via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group