Category Archives: Uncategorized

Health Wonk Review is up at Wright on Health

Wright on Health has posted the Repeal Fatigue Edition of the Health Wonk Review. You’ll find there a roundup of fine posts there, and thankfully they aren’t all about the implosion of repeal and replace. Topics include: vulnerable populations, opioids, workers comp and more.

Check it out.

Partners buys into Rhode Island: I’m quoted in the Boston Globe

Partners HealthCare plans to purchase Care New England in Rhode Island. Not a surprising move, considering  that Partners wants to continue to expand but is running into roadblocks in Massachusetts. Rhode Island is practically down the street.

I’m quoted in the Boston Globe’s coverage (Partners to acquire R.I.’s Care New England)

“This is a logical move for Partners, which has received strong pushback in its recent attempts to expand in Massachusetts, but is less likely to face the same pressures in Rhode Island,” said David E. Williams, the president of Health Business Group, a Boston consultancy. “The acquisition is geographically close to Partners’ existing network, and they already have a clinical collaboration. Rhode Island regulators will likely appreciate Partners’ financial strength and the stability it is likely to promote.”

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

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.

What if the FDA is eliminated?

President Trump’s first couple of weeks have people taking him literally, not just seriously. What does that mean when it comes to the regulation of drugs?

As I wrote in early December (Would an FDA radical make any real difference), I’m not convinced that even a major shift away from regulation will dramatically change the market. Even if the bar for approvals is lowered, third-party payers will still want to see compelling safety and efficacy data before they provide reimbursement. Medicare and Medicaid may also up their game by directly or indirectly discouraging prescribing of medications that are unproven.

The pendulum tends to swing back and forth between the demand for speedy approval and concern about harms to patients from inadequately tested drugs. Recently the pendulum has been swinging toward fast approval, and the newly enacted 21st Century Cures Act continues that trend.

But what will happen when a drug that’s rushed to market causes patient injury and death?

“We’re going to be cutting regulations at a level that nobody’s ever seen before. … And we’re going to have tremendous protection for the people — maybe more protection for the people,” Trump said Tuesday.

Trump is promising the impossible, and it may come back to bite him. Then again, maybe it won’t.

Goodbye Obamacare? More like hello single payer!

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Once Donald Trump enters office, Republicans will be in a good position to repeal Obamacare, something they have been foaming at the mouth to do for quite some time. Democrats might be able to filibuster to prevent an outright appeal, although the majority has other ways to gut the law, such as the reconciliation process.

I say let them go ahead and repeal Obamacare without putting up a big fight. As Trump told 60 Minutes, “I am going to take care of everybody. Everybody’s going to be taken care of much better than they’re taken care of now.” He also promised to provide “quality, reliable, affordable health care.”

I look forward to hearing the great ideas revealed by Trump and the Republicans in Congress. If they can do what they say then I’m entirely in favor of it and will give them the credit that’s due.

Meanwhile, I’m going to feel free to criticize the stock initiatives of the Republican party, which were largely mirrored in Trump’s campaign statements:

  • Repeal Obamacare, by which they really mean keeping the popular pieces like making health plans accept members with pre-existing conditions without charging higher premiums, but at the same time jettisoning the unpleasant aspects such as the individual mandate and taxes that help subsidize coverage. Sounds nice, but without a mandate, plans will suffer from adverse selection, premiums will skyrocket, and people will be left uninsured
  • Let health plans sell insurance across state lines. This one is highly touted but in reality it’s a big yawn. The plans themselves have little appetite for moving across borders and even if they did, most new entrants won’t be able to establish strong enough negotiating positions in the markets to bring down premiums
  • Change Medicaid to block grants so states can do what they want with the money. This isn’t a terrible idea because it could allow states to more freely innovate and tailor Medicaid to meet local needs. In practice it’s likely to be used just as a way to screw the poor
  • Promote drug re-importation. Remember the senior citizen buses to Canada in the 1990s before Medicare Part D and the mail order pharmacies with drugs supposedly from Canada, that disappeared once Obamacare required drug coverage? Well, the GOP might bring these back. But the drug market has changed and the most pricey new meds won’t necessarily be attainable from abroad anyway
  • Let individuals who buy their own health insurance take a tax deduction the way businesses already do. Again, sounds great in theory but it’s a regressive approach that rewards higher income people who are in the top tax brackets. It also encourages premiums to rise and widens the budget deficit. The Cadillac tax or some variant that limits deductibility by businesses is more fiscally responsible
  • Expand Health Savings Accounts (HSAs), allow them to be shared among family members and passed on as part of one’s estate. Not a bad idea but hardly a game changer in its own right

Remember, thought, that the Republican ideas above were presented by conservatives, while Trump himself has been at least a liberal and frankly more of a socialist when it comes to health care policy, at least based on his earlier writings. Once he learns that the ideas of the conservatives in Congress won’t produce universal coverage, he may well go back to improving –instead of replacing– Obamacare, moving to a Canadian style single payer system, or opening up Medicare for all, just like Bernie and much more radical than Hillary.

I can’t wait to see how it all plays out.

Image courtesy of Thanamat at FreeDigitalPhotos.net


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

 

Why I’m voting against marijuana legalization in Massachusetts

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I’m not dead set against the eventual legalization of marijuana for recreational use. Still, I’m strongly opposed to Massachusetts ballot question 4: Legalization,  regulation and taxation of marijuana, and will be voting No.

Why? Because the arguments in favor of approval are not strong enough to make Massachusetts one of the first states to legalize. And some of the arguments against the ballot measure raise serious concerns. Instead I’d like to take five years or so to observe  how things go in early-legalization states like Colorado and Oregon and apply the lessons in Massachusetts.

I thought Massachusetts did the right thing by de-criminalizing marijuana. That kept police and the courts from wasting resources on possession of small amounts of marijuana and stopped lives from being ruined through unfair imprisonment and the stigma of  a criminal record.

Voters then went further and approved medical marijuana, which as I expected, became a precursor to the push for full legalization just a couple years later.

The innovative Citizens’ Initiative Review Project summarized the pros and cons of Question 4. The strongest pros were as follows (quoted verbatim):

  • Legalized and regulated marijuana is safer than black market marijuana because the legalized product will be tested and clearly labeled according to state regulations.

  • Question 4 will create a large number of regulatory, law enforcement, legal, and licensure jobs that are supported by taxes on the sale of marijuana.

  • Question 4 would give patients and health providers ready access to marijuana without committing a crime. Legalization could help people avoid opiates, addiction and worse problems. 

The first point is accurate, however there is an implicit assumption that legalization will eliminate the black market. Colorado’s experience indicates that the black market may continue to thrive alongside the regulated, legal market, and that the official market is the province of middle and upper class white people, while the poor and minorities are priced out. So that’s not such a strong argument.

On the second point, it’s weird that one of the strongest arguments for a libertarian-oriented law would be to create large numbers of government jobs. That’s a terrible rationale as far as I’m concerned.

On the third point, there is already ready access to medical marijuana for patients and health care providers, thanks to the legalization of medical marijuana. There are some hints that people may be substituting marijuana for opiates. That’s probably a good thing and we should follow it closely.

The strongest “con” arguments from the Review Project include the views I expressed above about the black market and large number of new government jobs. The cons include two additional, compelling points:

  • Although in development, at this time there is no definitive method of testing for impaired drivers.

  • There is conflicting evidence of an increase in teen use or motor vehicle accidents in states that have legalized recreational use.

Beyond the Review Project’s findings, there are other good arguments against legalization. Marijuana is addictive for some people, it affects the developing brain in negative ways, and “edibles” are too easy for kids to get ahold of and to consume before or during school.

Please join me in rejecting Question 4 in Massachusetts in this election. If you do, I promise to be open minded about reviewing my stance in a few years, once evidence is in from other states.

Image courtesy of Paul at FreeDigitalPhotos.net

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