Health Wonk Review, kabuki style, and other noteworthy news briefs

Fresh HWR - Health Wonk Review, Kabuki Theater Edition is freshly posted by Brad Wright at Wright on Health. In this edition of the biweekly best of the health policy blogoshphere, Brad rounds up recaps and rounds up reactions to last week's Health Care Summit. A good edition, plus, some nice Japanese art prints!

Happening right now - On Thursday March 4 - that's today - from 9 am to 6 pm, join OSHA's live webcast, a first-ever live streamed public meeting. Over 200 people have registered to attend and more than 45 presentations will be made on to the Assistant Secretary of Labor for OSHA, Dr. David Michaels. If you can't make the event, keep up with OSHA happenings on its newly launched Twitter feed: http://twitter.com/OSHA

Google & pharma - At Health Business Blog, David Williams posts about the Google crackdown on ads for online pharmacies - only VIPPS-certified pharmacies (as selected by the National Association of Pharmacy Boards) will be allowed to post adwords. This will eliminate "rogue" pharmacies, which sounds reasonable. But it also eliminates Canadian pharmacies and some smaller outfits. Consumer protection or kowtowing to the big pharma interests? Read more about the controversy.

P&C industry: don't lump us in financial reform - have you heard about the Property & Casualty Leaders Coalition? You may yet. This is a new coalation eleven CEOs from the nation's largest property casualty insurance companies - among them State Farm Insurance, Allstate Corp., Travelers Companies Inc., Chubb Corp., ACE Group, Nationwide Insurance, Liberty Mutual, and Zurich Financial Services Group - who have banded together to urge Congress to leave them out of the financial services overhaul legislation. "There is no public policy justification for taking funds from companies in our industry, especially on a pre-event basis, to bail out other financial institutions deemed to be overexposed to failing ‘systemic’ companies."

How much risk is too much? - In Jobs to Die For, Yvonne Guilbert looks at people who risk their lives to work in jobs they love. One of the cases profiled is that of animal trainer Dawn Brancheau. Claims Journal features this related item: SeaWorld Death Raises Questions About Animal Entertainment Safety. And on the topic of high-risk endeavors with passionate participants, some are wondering if this year's winter Olympics went to extremes.

Director's cut - Here's a topic you won't see much about in the upcoming Oscar awards: Hollywood and risk. Fireman's Fund dishes up its annual list of the riskiest films it insures.

Other noteworthy briefs
At Comp Time, Roberto Ceniceros ponders Schwarzenegger's legacy and what comes next for California's workers comp.

Check out The Great Captive Shuffle, by Dave Lenckus of Risk and Insurance: Fresh blood courses through the captive regulatory veins in Vermont, Delaware, Arizona, Utah, Hawaii and Nevada, as new faces prepare to alter the captive landscape."

Joe Paduda always has the lowdown on the medical side of workers comp and this week, he has Texas covered in a recent pair of posts at Managed Care Matters: Texas' efforts to add science to the art of work comp medicine and Texas' efforts to control WC Rx.

Medicare and Physician Pay: Jim Bunning's Bean Ball

There are four things that are memorable about Jim Bunning's professional baseball career: First, tossing a perfect game for the Philadelphia Phillies against Trace Stallard and the New York Mets on the afternoon of 21 June 1964, lowering his ERA to 2.07 in the process (Phillies: 6 runs, 8 hits and no errors; Mets: Zip, Nada and Zilch); second, finishing second in the Cy Young voting in 1967 (Mike McCormick of the Giants won with 18 first place votes; Bunning got one, but, hey, it was good enough for the silver medal); third, from 1955 to 1963 while pitching for the Tigers, striking out Ted Williams more than any other pitcher Williams faced (and, as Jim Bouton's Memoir, Ball Four, tells it, Teddy Ballgame did not like it one bit); and fourth, entering the Hall of Fame compliments of the Veterans Committee in 1996.

About this time in Washington, DC, there are many Republican Senators, baseball fans all, who are wishing that the 6'3", 190 pound righthander had called it quits right there and retired to the backwoods of Kentucky. But, of course, he didn't. He had to go ruining it all by running for and winning a Senate seat from the blue grass state in 1998; and then he did it again in 2004! The political version of the Peter Principle.

Republicans politely call him "cantankerous" - at least that's what they say in public. Behind the scenes, they’re not so nice about it. Senator Bunning marches to his own drummer, and always has.

One Pitch, Three Strikes
He's retiring this year, but not before throwing one more hard-breaking slider (his best pitch back in the day). On Monday he managed something he never could in the Big Leagues - he threw three strikes with one pitch. By preventing a vote on an emergency spending bill, Senator Bunning: first, at least temporarily, killed an extension of unemployment and COBRA subsidy benefits for more than a million long-term unemployed Americans; second, shot down a short-term extension of the Highway Trust Fund, which is a federal fund set up to pay for transportation projects nationwide, after which Transportation Secretary Ray LaHood said that up to 2,000 employees at the Transportation Department will be furloughed without pay as a result; and third, insured that Medicare would immediately reduce fees to physicians by 21.3% via the Medicare Sustainable Growth Rate Factor (SGR). Wow, a "threefor!"

Strike 3 is what concerns us here. We've written often about the steep and steadily rising costs of Medicare, and now along comes Senator Bunning saying we have to lower costs and let's do it on the backs of hard-working primary care physicians. He certainly has a point that we need to lower Medicare costs, although he expressed it in a wild pitch sort of way. Here's a chart from the Centers for Medicare and Medicaid Services (CMS) that shows what will happen to Medicare costs in the future if nothing changes. The vertical axis is percentage of GDP:

And here's a summary from a Congressional Budget Office (CBO) Issue Brief on the Medicare Sustainable Growth Rate Mechanism (PDF). It's from September, 2006, but is still appropriate: The Supplemental Medical Insurance program (Part B of Medicare), which will cost about $158 billion in 2006, pays for physicians' services, outpatient hospital services, durable medical equipment, physical therapy, and certain other outpatient services. About 38 percent of those expenditures are payments for services provided by physicians, which are based on a schedule of fees that specifies the amount to be paid for each type of service. Most of Medicare’s payment rates are simply adjusted each year for inflation--but not those for physicians’ services (emphasis added). Those rates are governed by a complex formula -- the Sustainable Growth Rate (SGR) mechanism.

The SGR is pegged against a target originally established in the 1997 Deficit Reduction Act. Its aim is to hold down Medicare costs. It's calculated every year, and every year since 2004 this complex and nearly Byzantine calculation has called for an annual reduction of physician reimbursement rates by an average of 3% to 4%.

Nonetheless, every year since 2004 Congress, yielding to the medical lobby, has voted to override it by delaying the triggering of it. The trouble is, the law is cumulative. So, what Congress has done in a typically heroic display of moral courage, is to dig itself into an ever-deepening hole by not facing up to yet another looming catastrophe. Sound familiar?

Docs Rush the Mound
The AMA is nearly apoplectic about the SGR and the prospect of Senator Bunning causing it to be finally triggered. Monday, the organization was out in force in DC making its views known. The current President, Dr. James Rohack, went on Bloomberg and, later, CNN with Larry King. President-Elect Dr. Cecil Wilson even did an hour on Washington Journal C-Span answering questions from Democrats, Republicans and Independents, and, generally making his case.

And his case was that for a while now, physicians have been abandoning the Medicare ship, because, even though their Medicare fees have remained steady due to the congressional overrides, they claim they're losing money with Medicare patients because their costs have been inexorably rising. Moreover, it's no secret that there is an ever-increasing shortage of primary care physicians, and CMS reports that, while 92% of primary care physicians participate in Medicare, only 73% are accepting new patients. If nothing changes, that will surely drop precipitously.

Case in point – the Mayo Clinic, President Obama's iconic national model of high-quality health care efficiency, lost $840 million on Medicare in 2008, and, as of January 1, 2010, stopped seeing Medicare patients at its Glendale, AZ, clinic. The Mayo claims Medicare covers only 50% of its costs every time it sees a Medicare Patient.

So, we’re left with another one of those rock and hard place things. Medicare could bankrupt the nation, but physicians don’t get paid enough from it.

Yesterday, Congress stole second base on Bunning by extending unemployment and COBRA benefits for another month and by delaying the 21.3% Medicare physician pay cut until the end of March, at which time we'll probably have to go through this whole thing all over again. (Yogi Berra’s “déjà vu?)

Perhaps Senator Bunning's out of left field move will actually cause Congress to do something it has thus far been absolutely incapable of doing regarding our nation's health care. That is, fix it.

Right. And tomorrow 78 year old Jim Bunning will quit the Senate and to great expectations accept a $100 million free-agent contract to rejoin the Phillies as their Pitching Ace.

Noe Go: Con Man in a Corner

Four years ago (time flies when you're having fun!) we blogged the saga of Thomas Noe, the power broker who parlayed his relationships with highly-place politicos into lucrative contracts with the Ohio workers comp bureau. The state invested $50 million of comp funds in his coin business. Unfortunately, Noe's inventory of coins and his tracking of the funds fell short of bookkeeping standards. He was convicted on both federal and state charges. The "Coingate" scandal brought down some heavy hitters, including the governor.

In an article in the Columbus Dispatch by Mark Niquette and Joe Hallet, Noe outlines his next moves.

"God has a plan for me, and what I'm going to do (is) I'm going to make the best of my time in Hocking {Correctional Facility]," he says. Much of his time is tied up in his appeal, which is wending its way to the Ohio Supreme Court, where he subliminally hopes the judges remember him fondly: last time around, five of the seven judges removed themselves from a previous case because they had taken campaign contributions from the ever-generous Noe.

His appeal appears to be based upon a technicality: "Believe me, I'm not sitting here saying I didn't make mistakes. I made a lot of mistakes. I'm just saying I'm not guilty, in my opinion, of what they said I'm guilty of."

To put it mildly, the prosecutors aren't buying Noe's claiming of innocence.

Assistant Lucas County Prosecutor John Weglian says: "He's a liar."

"There isn't a single embezzler in the history of embezzling, I think, who has not intended to pay the money back," Weglian said. "They all say that. ... He's a salesman; he's trying to market himself." (With all due respect, Mr. Weglian, Bernie Madoff knew all along he was never going to pay people back.)

Accentuate the Positive
For the disgraced Noe, the marketing options from a jail cell are clearly limited. But Noe prides himself on being a positive person.

"I've always said a negative thought's a down payment on failure. I'm not going to fail. I'm not going to fail on the outside. I'm not going to fail as a prisoner."

One might argue that Noe's conviction on multiple charges of corruption was a failure on the outside, and that his prospects for success from the "inside" are remote. But as Noe says, it's just part of God's plan - a plan, at the moment, that calls for another decade or so in Hocking. The former high roller used to enjoy steaks and cabernet at the best restaurants in Ohio. His current fare falls rather dramatically short of that standard, but, heck, it's free and there's no tipping.

It would be nice to think that if he ever gets another opportunity to make business decisions on the outside, Noe will have learned how to say "no way" to the Noe Way. I'm not exactly holding my breath.

On redefining disability

When is a worker disabled and unable to do his or her job? This is an issue that surfaced in a recent post about an employer that was reluctant to make workplace accommodations for employees who had been injured on the job but who wanted to return to work. This case came to mind again after viewing a presentation by record breaking athlete Aimee Mullins. In her most recent appearance at the TED conference, Aimee delivers an outstanding talk that properly redefines the word 'disabled.' The video clip is about 22 minutes, but it's guaranteed to be one of the best things you see this week. Here are a few excerpts that we liked:

"It's not just about the words, it's what we believe about people when we name them with these words - it's about the values behind the words and how we construct those values. Our language affects our thinking and how we view the world and how we view other people."

"...we have to make sure that we don't put the first brick in a wall that will actually disable someone. Perhaps the existing model of only looking at what is broken in you and how do we fix it serves to be more disabling to the individual than the pathology itself. By not treating the wholeness of a person, by not acknowledging their potency we are creating another ill on top of whatever natural struggle they may have."

More about Aimee Mullins
TED profile - with links to additional presentations she has made
Aimee Mullins website
Aimee Mullins on Wikipedia