Thursday, October 30, 2008

What Requires 17 Licensing Boards? 

Minnesota's regulation of health care professions

By John LaPlante

Categories:  Minnesota

Here's more evidence that health care is not exactly offered by a market devoid of government intervention: In the state of Minnesota, 47 health-related professions are subject to state regulation. Overseeing all this are 17 licensing boards and two divisions of the state's health department.

An issue brief from the House Research Department lays out some of the methods of regulation, such as licensure, registration, certification, a "bill of rights" and of course civil and criminal penalties.

Some of these rules may promote some measure of public safety. But they also make it more difficult to enter the relevant professions and add to the cost of doing business, which in turn feeds into the cost of health care generally.

• posted by John LaPlante
• 5:25 am
• 0 comment

Thursday, October 23, 2008

University of Minnesota Proposes Far-Reaching Conflict-of-Interest Policy 

By Peter Nelson

Categories:  Minnesota

The Star Tribune recently reported that the University of Minnesota “is considering a new conflict-of-interest policy so strict that doctors wouldn’t even be able to accept Post-it Notes bearing a drug company’s logo.”  After reading through the medical school's proposed policy, here’s my initial reaction. 

To begin, transparency -- especially when a patient is seeking advice at a moment of extreme weakness -- is vital.  Most of the task force recommendations seem to be appropriate steps toward transparency and doing away with any appearance of conflicts of interest.

However, I do worry that the proposed recommendations might lead to at least two unintended consequences: Less university-driven innovation and fewer local doctors participating as unpaid or adjunct faculty. 

Innovation might suffer for two reasons.  First, when the U of MN institutes a more stringent policy ahead of other research universities, device manufacturers and pharmaceutical companies -- believing secrecy helps them maintain a competitive advantage -- may pull their collaboration with university faculty and, instead, work with faculty at less transparent universities.  It's no secret that businesses gravitate to where there is less regulation.  63 percent of Fortune 500 businesses are incorporated in Delaware due to the state's friendlier regulatory and legal atmosphere.  This suggests that a national policy would be a better approach.  (We'll be able to test this theory now that Massachusetts stepped out front with the country's most strict medical device transparency law.) 

But there's a second problem that a national approach would not fix.  If every company across the nation were forced to disclose their financial relationships with doctors, small companies and startups may have a more difficult time competing with the big companies.  The fact is, companies do not always play fair.  If word gets out that a particular doctor started consulting for a start up, another company might try to disrupt that relationship.  Furthermore, a company will be tipped off to the type of product being developed, which may lead them to push up the development of a similar product or stall the other company through patent litigation. 

What we should be concerned about is the patient relationship and, in that setting, full transparency should be expected and demanded.  These recommendations appear to go beyond that and require full transparency to the public.  Specifically, one recommendation suggests creating a website  “to allow full transparency of research conflict-of-interest activities.”  The task force should clarify the level of disclosure expected and consider a different approach that allows consulting relationships to remain nonpublic for a certain period of time while drugs and devices are being developed.

Finally, if local doctors know that they will be subject to this level of transparency when they become unpaid or adjunct faculty, they may decide serving the medical community isn't worth it and choose to stay completely private so that they can continue to work with companies free from public scrutiny.  For faculty with a minimal university affiliation, the recommendations should apply only to conflicts-of-interest arising from university-related research and patient care.

I imagine a number of other unintended consequences might surface and so it's nice to know that Leo Furcht, the co-chair of the task force, treats the report as a "living document" to be "fine-tuned."

• posted by Peter J. Nelson
• 4:46 pm
• 0 comment

Thursday, September 25, 2008

You Don't Say 

Report: Better to have private insurance

By John LaPlante

Categories:  Minnesota

A new report from Minnesota says that during 2006, the "quality of care provided to public program patients was behind that provided to other patients."

So why the continued rush to put more people into government programs, both in Minnesota and across the country? It's time to de-governmentize the health care sector.

• posted by John LaPlante
• 10:27 am
• 0 comment

Wednesday, September 17, 2008

Brokeback Mountain: Are Health Costs Killing Ranchers, Farmers? 

Access Project Report Repeats Myths of "Underinsurance"

By John R. Graham

Categories:  Insurance Regulation, Iowa, Minnesota, Missouri, Montana, Nebraska, North Dakota, South Dakota

One of America's health care zombies that refuses to die is the notion (created by the Commonwealth Fund) that millions of people who have health insurance are "underinsured", largely due to policies with high co-payments and high deductibles.  This results in "medical bankruptcy", another exaggeration.

The Commonwealth Fund's conclusions have been picked up by an organization even more committed to "social justice", The Access Project, which advocates for ranchers and farmers in the heartland.

The Access Project has just published the results of a survey of ranching and farming in a number of states - with dire conclusions.  The facts are a little less dramatic than advertised.

Nobody argues the case for health reform more vigorously than the bloggers at SPN, but when nine of ten ranchers and farmers have health insurance (as TAP reports), it's hard to conclude that the home on the range is surrounded by the bleached bones of homesteaders driven into medical bankruptcy.

Like the Commonwealth Fund, TAP defines "underinsured" as spending more than ten percent of a household's income on health care in one year.  Clearly, this definition is inadequate because it ignores the lifecycle of earning, saving, and spending.  If you spent one percent of your income on health care for thirty years, and eleven percent this year, you are "underinsured".  If you spend nine percent every year of your life, you are considered adequately insured!

Also, like the Commonwealth Club, TAP dislikes people buying health insurance which we prefer, in the individual market.  Instead, TAP prefers the group market, where the tax code drives most of us into the arms of our employers to use health plans that they prefer.

This is because TAP is unwilling to understand that, although the individual pays 100% of his premiums directly in the individual market, he pays only a small fraction of the premiums in the group market.  (According to TAP's survey, median spending on premiums and out-of-pocket payments for individually insured households was $11,700 in 2007, versus $5,600 for those covered in the group market.)

Nevertheless, the person insured in the group market pays more indirectly, because his wages are decreased by the amount that his employer pays for his plan.  Thus, the individually insured, overall, pays somewhat less for health care.  (Other research, although "spun" in opposition to individual policies, calls this "actuarial equivalence".)

Consumer-directed, individually purchased, health policies are not just for us arugula-eating, chardonnay-sipping, San Franciscans.  They're for ranchers and farmers in America's heartland, too.

• posted by John R. Graham
• 7:03 pm
• 1 comment

Wednesday, September 17, 2008

Good Medicine = Good Policy? 

By John LaPlante

Categories:  Minnesota

David Strom, president of the Minnesota Free Market Institute, says the vernerable Mayo Clinic has gone wading into a health care swamp with "a proposal that has something for everybody to hate."

Strom says that Mayo's proposal for changing the health care system resembles its method of practicing medicine, which is to build "an integrated system that taken as a whole will provide the best possible outcomes for patients."

So does the good practice of medicine translate into a good health care policy proposal? Strom asks some questions:

1) is creating a health care “system” desirable? After all, we don’t have a food delivery “system,” or housing delivery “system,” so why a health care delivery “system?” 2) Wouldn’t such a system undermine the freedom of individuals and providers compared to what exists today? And 3) if it does make sense to follow Mayo’s path, how can we get from here to there?

He says that the Mayo proposal "takes a small step" towards putting the patient back in charge of our health care ... uhm, "system," by making insurance portable. But otherwise, he's skeptical that Mayo's top-down approach will work well.

• posted by John LaPlante
• 2:37 pm
• 0 comment

Thursday, September 11, 2008

Bush Administration Threatens to Cut Low-income Parents from SCHIP in Minnesota 

By Peter Nelson

Categories:  Minnesota, SCHIP

More news on the Bush administration’s efforts to crack down on SCHIP is coming out of Minnesota. John Graham of the Pacific Research Institute just explained how the administration appears to have backed down on enforcing its rule restricting SCHIP expansion in states that do not demonstrate that they’ve enrolled 95 percent of eligible children. Instead, the administration is flexing its muscle in Minnesota.  Last month the Centers for Medicare and Medicaid Services (CMS) denied Minnesota’s application to extend its Medicaid waiver that allows Minnesota to use SCHIP funds for adults. Minnesota had a month to appeal the ruling and just yesterday received a two-week extension.

Many people (especially readers of this blog) might be thinking it’s about time SCHIP stopped funding adults in Minnesota. After all, SCHIP was created to fund health benefits for children. Indeed, Minnesota has long been the whipping state on this issue because nearly all of its SCHIP funds go to adults. 

But not so fast. Minnesota only funds adults because it already funded children prior to SCHIP. Because SCHIP was intended to reduce the number of uninsured children, it specifically disallowed extra funding to state programs that already insured children. This SCHIP provision is called the maintenance-of-effort requirement.  The idea was that extra federal funds should only go to uninsured kids and so states already putting forth an effort should be forced to maintain that effort as a prerequisite to receive funding for further expansion.

The maintenance-of-effort requirement was patently unfair to taxpayers in Minnesota and those other states that already expanded health care programs for children. Minnesotans were already using their hard-earned tax dollars for their own program and then SCHIP came along and tried to dig more money out of our pockets to pay for children in other states.

CMS gave Minnesota an appropriate level of flexibility to cure this inequity. Without that flexibility, Minnesota would be forced to spend SCHIP dollars on children in families with incomes above 275 percent of federal poverty guidelines as opposed to funding parents in families below 200 percent of FPG. Which families do you suppose need the funding more?

Now CMS wants to take funding away from those parents.

Well, Minnesotans can be forgiven for wanting to keep Minnesota dollars in Minnesota, which is why the entire Minnesota congressional delegation, including stalwart conservatives like Michele Bachman and John Kline have asked HHS Secretary Leavitt and CMS to reconsider pulling its funding for Minnesota's SCHIP program.

• posted by Peter J. Nelson
• 7:11 pm
• 0 comment

Monday, August 18, 2008

Anatomy of a Rebellion 

By Mark Todd Engler

Categories:  Minnesota

A piece in the Minneapolis Star-Tribune today puts a healthy spin on concierge medicine and cash clinics.

The article examines some of the rewarding and revolutionary possibilities awaiting physicians willing to buck the system and venture in creative new directions.

The gist: What's good for doctors is, not surprisingly, also often what's good for patient-care:

(Dr. Michael Oldenburg is) among a sprinkling of Twin Cities doctors escaping the pressures of modern American medicine by striking out on their own. Some are offering "concierge care," where a limited number of patients pay a membership fee for 24-hour access to a physician. Even University of Minnesota Physicians is experimenting with a small clinic opening soon in Minneapolis' Warehouse District, where two doctors will make house calls on bicycles.

These experiments amount to tiny rebellions against increasingly large and impersonal health care systems and their emphasis on the bottom line. But they also speak to a hankering for something many doctors feel they've lost in the hurly-burly of seeing up to 30 patients a day -- the personal relationship between doctor and patient.

• posted by Mark Todd Engler
• 5:29 pm
• 0 comment

Friday, August 15, 2008

U.S. Index of Health Ownership 2nd Edition Is Here 

Alabama up, Utah down, New York still in the basement: Where's your state?

By John R. Graham

Categories:  Alabama, Alaska, Arizona, Arkansas, California, Certificates of Need (CON), Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Hospitals, Idaho, Illinois, Indiana, Insurance Regulation, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Medicaid, Medical Malpractice, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Retail Clinics, Rhode Island, SCHIP, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming

Pacific Research Instite has published the 2nd edition of the U.S. Index of Health Ownership, the only ranking of health care in the states that uses criteria of individual choice.

Americans lack the basic freedom to make their own health care decisions.  The Index measures the degree to which individuals, be they patients, health professionals, entrepreneurs, or taxpayers, "own" the health care in their states.

The lack of health ownership is a real problem. Almost half of the country's health care spending is in the hands of the government, instead of patients themselves. The other half is governed by regulations inflicted upon doctors, health plans and patients.

The Index uses 24 variables to quantify how state laws and regulations affect the liberty of citizens involved in state government health plans (primarily Medicaid), the private health-insurance market, and the provision of medical services. It also assesses the effect of medical tort on people's freedom to engage health services.

Alabama, Montana, Nebraska, North Dakota, and New Hampshire finished in the top five, as the states that allow their citizens the highest degree of health ownership. Alabama leads the pack primarily because of a lightly regulated private insurance market, and good control of state government programs. Also, the state performs well on medical tort indicators. Alabama's regulatory environment for providers favors competition, and government health programs run more effectively than in most states.

New York, Massachusetts, Rhode Island, Vermont, and North Carolina rounded out the bottom five, as the states in which the government has taken the most undue control of health care from its citizens. This is the second year that New York was in last place. The state suffers from government health-care programs that are out of control, a grossly overregulated private-insurance market, and almost completely uncompetitive provider markets.

A full listing of all 50 states and their rankings is contained in the Index.

The Index will give concerned citizens a good basis to demand reforms from their state politicians that will put American families in charge of American health care, instead of government and special interests.

• posted by John R. Graham
• 5:33 pm
• 1 comment

Thursday, August 14, 2008

MN Health Dept. Posts 2008 Reforms Summary 

By Peter Nelson

Categories:  Minnesota

This year Minnesota passed a broad set of health reforms that aim to promote healthy behaviors, align provider payments with value, standardize certain administrative procedures, expand Medicaid to more adults, encourage broader use of Cafeteria plans, mandate payment for medical homes, and require the adoption of e-prescribing and interoperable electronic health records.

For anyone interested in the state's perspective on these reforms, the MN Deptartment of Health just posted a series of web pages summarizing them.

• posted by Peter J. Nelson
• 11:27 am
• 0 comment

Monday, July 14, 2008

Housing assets should help finance long-term care 

By Peter Nelson

Categories:  Long-term care, Minnesota

A recent decision from the Minnesota Supreme Court documents how the average senior can qualify for Medicaid long-term care financing while still maintaining a substantial amount of assets in there home.  In a commentary published on MinnPost today, I recount the facts of that decision and how federal Medicaid law can actually restrict states from recovering housing assets from the estates of certain married couples.    More broadly, the case highlights maybe the last substantial Medicaid long-term care qualification loophole and reminds us that our  public long-term care financing system is plainly not working.

While the case is only binding in Minnesota, the case represents a sound interpration of federal law and  will likely influence how other states interpret federal Medicaid estate recovery law.  In fact, the message here is actually more important for other states to heed because Minnesota happens to be one of the few states that actively pursues assets from the estates of Medicaid recipients.

• posted by Peter J. Nelson
• 5:26 pm
• 0 comment