Category Archives: Policy and politics

USPSTF adopts my reasoning on PSA screening for prostate cancer

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Which way on PSA?

I oppose over-testing and over-treatment, so I really had to think hard five years ago when I turned 45 and my doctor offered PSA screening for prostate caner. The US Preventive Services Task Force (USPSTF) had just come out against PSA screening, concluding that the harms outweighed the benefits.

Nonetheless (Why I decided to get a PSA screening test for prostate cancer), I did go forward. As I wrote:

I know that PSA is a very imperfect indicator. I definitely want to avoid the stress and possible discomfort of having a biopsy. I’m worried about false positive and false negative biopsy results. And I don’t relish the significant potential for incontinence, impotence, or bowel problems from treatment.

But at this stage of my life I am willing to accept a significant risk of morbidity in exchange for a small reduction in mortality risk, which is my impression of what my choice to have the PSA test means. In 10 or 20 years I probably won’t feel that way. And I hope there will be better detection, follow-up and treatment options by then.

I’m also confident in my ability to make informed choices with my physicians along the way. The PSA test itself was done as part of routine blood work and there was no additional risk from that. My doctor and I agreed that if the PSA is elevated we’ll discuss what to do next. At that stage I’ll also have the chance to do more research and get more opinions if necessary. I’m not automatically going to get into a cascade of follow-up and treatment.

Now the USPSTF appears to be coming around to my way of thinking. In particular, they note that more men are choosing “active surveillance,” i.e., keeping a close watch rather than jumping straight to aggressive treatment.

The choice about whether to undergo PSA testing and what to do once results are in is a great opportunity for shared decision making. And this is what should be encourage.

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

Trump’s next health care bill: Medicaid for all?

Donald Trump knows almost nothing about healthcare policy. He doesn’t know what’s in the ACA/Obamacare or how it works –just that it’s a “disaster,” and since the abandoned American Health Care Act ran directly counter to his promise to “take care of everybody” it’s fair to assume he doesn’t care about what’s in these laws either. He just wants a big win.

A lot of the populist attacks on Obamacare boil down to the individual exchanges/marketplaces. People complain about high and rising premiums and point their finger at Obama. Frankly, I’m skeptical about many of these complaints. Premiums were rising faster before the exchanges came into being and it was often impossible to get insurance if you were sick or had a pre-existing condition. Also, most Obamacare exchange users receive significant subsidies and many receive help on out-of-pocket payments as well. And let’s remember that Republicans at the state and federal level have been trying to sabotage the exchanges by refusing to set up state exchanges (despite supposedly being in favor of state-level control), not funding risk corridors, not advertising for members, resisting the hiring of exchange navigators, spreading misinformation about the program, and more.

But I say to Obamacare haters: go ahead and unplug the exchanges. They are a Republican idea anyway. Replace them with something better if you can think of it –my guess is you can’t.

Now, what to do with the people who are thrown out of coverage by a shutdown of the exchanges? The Congressional Republican approach appears to be to let insurers sell skinnier policies that more people can afford, while enforcing the retention of popular Obamacare policies like a ban on medical underwriting and allowing people to stay on their parents’ plans to age 26. That won’t work –as they’ll find out if they ever put it in place, and the number of uninsured people will skyrocket.

So here’s a radical idea: kill off the exchanges and let insurers do whatever they please in the individual market. But at the same time make Medicaid available as a cheap backup plan for anyone who wants it. It will be free for the poor as it is today, but others can pay some fraction of the cost based on their income. No need to rely on the Obamacare exchanges in that case. And Medicaid is better than other federal and private programs at keeping costs under control, so it will be a double win. We already see that the Medicaid expansion is becoming popular in Republican led states, so why not just expand it some more?

Obamacare opponents can dress up the Medicaid for All bill however they like. In fact, why not include some of the big GOP “ideas” that will have little to no practical effect and say that’s what made the law work? I’m referring to allowing health plans to sell across state lines, promoting drug reimportation, allowing tax deductibility for individuals’ purchases of health insurance, and expanding Health Savings Accounts.

As I’ve said in the past (Goodbye Obamacare? More like hello single payer!) Donald Trump will have us on the path to socialized medicine faster than you can say Vladimir Vladmirovich Putin.

Images courtesy of Thanamat and Stuart Miles at FreeDigitalPhotos.net

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

Health Wonk Review is up at Colorado Health Insurance Insider

The Aye or Nay on AHCA edition of the Health Wonk Review has just been posted at Colorado Health Insurance Insider. You’ll find a number of fascinating policy posts related to the American Health Care Act that’s due for a House vote today.

Thank you to our host, Louise Norris for prominently featuring my 12th birthday edition.

Health Wonk Review: Presidents’ Day edition

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With Presidents’ Day on Monday, school vacations in Massachusetts and New York, not to mention the throngs soaking it up at HIMSS, it’s relatively quiet in the healthcare wonkosphere this week. Nonetheless, I have managed to collect a few solid entries for your reading pleasure.

Workers’ Comp Insider has a “bone to pick” with former President Obama for not doing enough to fight for ObamaCare and educate the public about its merits. But the last few lines are telling as the post focuses on the cluelessness of the ‘dogs that caught the bus’ (i.e., Republicans). And the PS says it all.

Managed Care Matters notes that mayors lose their jobs when they do a poor job cleaning up after a snowstorm. That’s what may happen to the GOP at a national level with healthcare, except that healthcare is a lot more complex than snow removal. We shouldn’t expect much real progress on healthcare legislation anytime soon.

InsureBlog has been cheering for ObamaCare’s demise since before there was an ObamaCare, and its Running out the clock post continues on that theme. The new news: Repeal may not be needed if current trends continue, including Trump’s executive order that removes enforcement mechanisms for the individual mandate.

Health Affairs blog explains the Trump Administration’s Market Stabilization Proposed Rule, which is designed to keep the individual insurance markets viable for health plans while the GOP ponders what to do longer term. Colorado Health Insurance Insider explains the implications of the rule overall and for Colorado specifically.

Healthinsurance.org warns that ObamaCare supporters won’t go quietly into the night. The Families USA conference reminds us that ACA repeal isn’t inevitable and that grassroots communications strategies to preserve gains in coverage and access can be effective.

In my Health Business Blog post on the Cadillac Tax, I speculate that Congress may leave the unpopular levy in place rather than expending energy on the politically difficult initiative to replace it with a GOP version that does essentially the same thing with a different name.

As I understand it, it’s really easy to extract oil in Saudi Arabia because rich deposits are right near the surface. When it comes to locating conflicts of interest, Health Care Renewal now finds itself living in the equivalent of Saudi, where Trump Administration officials from the President on down are barely trying to conceal their conflicts. Today’s tale is: Making health care conflicts of interest great again. A consultant to Medicaid and simultaneously to Medicaid vendors for CMS?

The ever insightful Drug Channels analyzes data from Express Scripts to conclude that having the government (or maybe Mr. Trump himself?) take over drug price negotiations for Medicare wouldn’t actually reduce overall costs. There’s utilization management to take account of, not to mention the impact of drugs on overall healthcare costs.

Image courtesy of nirots at FreeDigitalPhotos.net

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

 

Can Congress agree on the Cadillac tax?

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Cadillac taxi?

Health care is too costly in the US. One reason is that health insurance premiums are fully tax deductible for employers. This distorts the market, causing employers and employees to prefer devoting the next dollar of compensation to healthcare rather than wages. That’s fine in any given year but over time it’s helped drive up healthcare spending and hold down wages.

One of the many things the Affordable Care Act did right was to start to address this issue with the so-called Cadillac Tax, an excise tax on high cost employer plans. Like everything in the ACA it has been attacked and derided by the law’s opponents. But many Republican plans have equivalent measures, which would cap the deductibility of health insurance. Either one of these approaches would help by causing employers to work harder to hold down healthcare spending and by generating tax revenue that could be used for other health law goals or for general purposes. The end of tax deductibility only kicks in at a high threshold, which means the impact in the early years is limited and everyone has time to get used to the new rules. I’d like to see Congressional leaders be brave and embrace some form of cap as a bi-partisan consensus move.

Alas, the caps are opposed by an array of forces: employers don’t want a new tax, labor groups are worried that benefits will be eroded and out-of-pocket costs increased, and the healthcare industry worries about a squeeze on revenue.

Without strong leadership in Congress, it seems doubtful that new legislation will be passed. So maybe the best bet is to leave the Obama era Cadillac tax in place, imperfect as it may be.

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