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We're delighted to be hosting Health Wonk Review this month. In looking for a potential theme, we turned to "the Googles" to see if January was noteworthy for any special commemorations beyond Martin Luther King day. Well buckle down because it looks like we will all be very busy. January is apparently train-your-dog month, radon awareness month, "get organized" month, crime-stoppers month, budget month, cervical health awareness month, closet organization month, mentor month, beer month, pet registration month, anti-human trafficking month, tuna month, pork month, and more - we're sure we've missed some and we're exhausted already.

We've decided to go with beer month (as we wrote this last night) and a turn to the classics: January is named after Janus, the ancient Roman god of the doorway. Janus is generally depicted as a two faced god, with one face looking to the past and one to the future. Here on Health Wonk Review, our last issue included some recaps of the prior year, so in this issue, we are looking to the future and what the coming year might hold for healthcare.

Reading the tea leaves
Since our last issue, several of our intrepid wonks have proffered prognostications for the coming year. First up is Joe Paduda at Managed Care Matters who offers his workers' comp predictions, which are expansive enough to encompass not one post, nor two, but but three - and if he is right, it looks like it will be a busy year in the occupational medicine arena.

At The New Health Dialogue Blog, Joe Colucci notes that the countdown to the SCOTUS ruling on the Affordable Care Act has begun, and weighs in with prognostications about how the constitutionality challenges are likely to fare.

At InsureBlog, Bob Vineyard looks ahead at the future of healthcare, finding some things you won't get on the 6 o'clock news.

The devil-some details
While some of our posters are looking at the broad trends, others are looking under the hood. As the saying goes, the devil is in the details.

At Health Affairs Blog, Timothy Jost examines the first set of Supreme Court briefs filed in the challenge to the ACA, including the U.S. government brief defending the constitutionality of the minimum coverage requirement, aka individual mandate.

At Health Care Renewal, Dr. Roy Poses takes a bipartisan look at the presidential candidates and their financial relationships with large health care organizations, wondering whether any of them would be inclined to advocate for health reform measures that might threaten the interests of these organizations. He notes that some of these relationships appear significant enough to be called conflicts of interest in arenas other than the political one, yet none of the candidates has made a point of disclosing these relationships as potential conflicts.

Louise Norris of Colorado Health Insurance Insider examines some of the potential reasons why claims expenses in Colorado's new high risk pool are double the national average. She points out that, "pre-existing condition exclusion riders have all but disappeared in the individual health insurance market in Colorado. Nearly all carriers now use underwriting rate increases instead."

On the eponymously named John Goodman's Health Policy Blog, John examines barriers that physicians face in pricing and packaging their services in a post entitled How Doctors are Trapped.

David Williams of Health Business Blog looks at Medicaid expansion and questions if we will we get our money's worth. He notes that as more diabetics are added to the rolls, their out of pocket costs will fall. But overall costs will rise steeply and it's unclear whether outcomes will improve.

Healthcare Economist Jason Shafrin investigates how Medicare's physician value-based purchasing scheme will work. He notes some of the challenges involved in evaluating physicians for quality and cost.

Brad Wright is looking sharp at his newly designed blog, Wright on Health, where he offers an overview of the Independent Payment Advisory Board, the mechanism created by the Affordable Care Act to deal with growing Medicare spending. He looks at how it works, as well as what it can and cannot do.

Gary Schwitzer looks at senior health care policies from another perspective. He earns his Health News Watchdog blog name as he digs up the truth about a dishonest health care hoax intended to scare seniors which has recently been making the rounds, including airtime on a national radio call-in show.

And for another angle on senior care, at Health AGEnda, Marcus Escobedo looks at the issue of life expectancy and whether it should affect treatment. His post discusses a new evidence-based website for predicting life expectancy among older patients, ePrognosis.org, and the debate surrounding its use.

On the technology front...
Primary care physician Jaan Sidorov believes the digitization of health care information will commoditize primary care. At Disease Management Care Blog, he examines the transport of information and the likelihood that, when it comes to routine medical problems, patients won't need to be seen by a physician in a traditional face-to-face visit.

Also on the healthcare technology front, Dr. Michael Koriwchak has a post a Healthcare Talent Transformation where he takes a closer look at the "enthusiasm gap" between Health IT startup companies and physicians and opines about some of the reasons for barriers to adoption.

Closing thoughts...
At Corporate Wellness Insights, Kat Haselkorn reminds us that wellness can be a good investment with a good ROI, and that ignoring workplace wellness is as risky as gambling because no employee is immune to illness or injury.

Here at Workers Comp Insider, we point you to our piece on How Doctors Die, recounting a thoughtful article by a physician who notes that, "What's unusual about them is not how much treatment they get compared to most Americans, but how little."

Next up: Our next edition of Health Wonk Review will be hosted by Louise Norris at Colorado Long Term Care Insider on February 2!

We've bringing you something a bit peripheral to our normal topics today, but it deals with the business of medicine. Plus, it is excellent.

How Doctors Die by Ken Murray, MD talks about how doctors face end of life issues. Many might assume that when faced with a terminal condition, physicians would leverage their expertise and access to the max, harnessing all the latest treatments and technologies. But the picture that Murry paints is a very different one. Armed with the knowledge of just how grueling and terrible the "do everything possible" model can be, many doctors choose to forgo chemo, radiation, surgery, and other life-prolonging treatments entirely.

"What's unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently."

Why, if they don't want this treatment themselves, do they inflict it on patients? Murray explores the many often human reasons why family members and physicians make these choices and points to a system that encourages and rewards excessive treatment and unrealistic expectations about what medicine can do. Plus, as a society, we have a cultural bias against accepting death. Perhaps it was ever so - no one want to die. But advertising, a stay-young-forever culture, pharmacology, and the miracles of technology all conspire to make us think we perhaps can live forever. When someone facing a terminal illness chooses acceptance of the natural order, they are often pressured by family and friends for not being a fighter.

The comments in the article are also well worth reading. Other people -- doctors, medical professionals, and "civilians"-- offer their thoughts, opinions, and touching real life experiences with family members, friends, and even their own terminal circumstances.

From time to time, we like to take a look at the wizardry that is under development in rehabilitative and assistive technologies. What used to be on the order of Flash Gordon type fantasy is now reality within reach. In out first clip, Toyota Unveils Quartet of Healthcare Robots. MedGadget says these four robots are expected to be production ready in 2013. Three are walking assist and balance training robots that would help in patient rehab. The fourth is a patient transfer assist - something we see as very valuable in helping to prevent health care worker injuries.

And while on the topic of lifting aids, we'd be remiss if we didn't include RIBA, a versatile if somewhat surreal patient care robot.

Finally, we have a Robotic Man's Best Friend to Guide the Blind. Yes, it may cost a bit more, but think of the savings in dog food. All joking aside, it's exciting to see these technological advances moving closer to the practical reality of helping people to overcome injuries and disabilities.

Today we examine two court cases that trouble the dreams of claims adjusters: workers with severe injuries whose use of pain medication leads to their deaths. In one case, the accidental overdose is deemed compensable; in the other, the claim is denied. The devil, of course, is in the details.

Compensable Death In Tennessee
In November 2008, Charles Kilburn was severely injured in an auto accident while in the course and scope of employment. Fractures to his back and neck resulted in permanent total disability. Following surgeries, he still experienced severe pain. A pain specialist prescribed oxycodone. Fourteen months after the accident, Kilburn died of an accidental overdose. His widow filed for death benefits.

Kilburn's employer believed that the death was the result of negligence, which would break the chain of causality with the original injury. Kilburn had ignored his doctor's cautions to limit his intake of oxycontin to a specific maximum dose. The Supreme Court of Tennessee determined that the severe pain experienced by Kilburn might result in diminished faculties, which in turn might lead to taking more medicine than was prescribed. In their view, the chain of causality remained intact at Kilburn's death and thus his widow was entitled to benefits.

Denial in Ohio
In Parker v Honda of America, the initial circumstances are similar, but the apparent "diminished faculties" lead to a very different result. John Parker suffered a severe back injury at work in 1988. He was prescribed OxyContin in March 1999. He eventually became addicted to the drug, along with cocaine, percocet and heroin. In March of 2006 he was found dead, a syringe in his arm, a spoon with a lethal dose of melted OxyContin at his side. In this case, the Ohio Court of Appeals found that his melting and injecting the drug, combined with his documented abuse of street drugs, broke the chain of causation linking the death to the workplace injury.

The court rejected his widow's argument that the drug abuse was the result of a "severe disturbance of mind" and thus unintentional. It's worth noting that if Parker had deliberately overdosed as an explicit act of suicide, the death may have been deemed compensable. But because the overdose was an acccident, workers comp benefits were denied.

The Big (and Not-So-Pretty) Picture
Pain is a constant factor in work-related injuries. The control of pain is a complex and widely misunderstood aspect of claims management. Because we live in a culture that relies heavily on powerful medications to control pain, and because the prescribing of these powerful drugs is neither well managed nor well monitored, we will see more and more cases of drug overdoses wending their way through the workers comp system. Some cases will be compensable, others will not. One thing is certain: the challenges of managing these situations will continue to haunt key players in the comp system: the doctors who prescribe the drugs, the adjusters who authorize bill payment, the families who suffer the consequences of loved ones in severe discomfort, and above all, the injured workers, whose every waking moment is compromised and consumed by a pain that just won't go away.

Florida is famous for at least three things: citrus fruit, sunshine and pain pills. The citrus and sunshine are pretty much permanent, but it appears that the easy dispensing of opioids may be coming to an end. HB 7095, the state's new law regulating opioid distribution, bans doctor dispensing of drugs and subjects pharmacies to inspection of prescription records. The state is determined to put an end to its reputation as the pill mall of America.

Now CVS, the giant pharmacy concern with over 700 stores in Florida, has stepped into the breach. They have notified a small number of doctors that they will no longer honor their prescriptions for opioids. CVS has analyzed prescription data and determined that these doctors are over-prescribing. As with so many issues involving insurance coverage, the data goes into a black box and a determination comes out the far end. What happens in the box remains a mystery. Our esteemed colleague, Joe Paduda, has strongly endorsed the CVS effort at his Managed Care Matters blog.

Feeling the Pain
It should come as no surprise that a key stakeholder in the use of opioids, the Florida Academy of Pain Medicine, is crying foul. The academy points out that the criteria for blackballing doctors is unknown and that doctors - and only doctors - should be allowed to determine who needs pain killers and for how long. As Jeffrey Zipper, chair of the Academy's Medical Affairs committee puts it, "I don't want to be subject to the scrutiny of CVS."

Given the immense dimensions of the prescription drug problem in Florida, it's clear that some doctors have long been abusing their power to prescribe medications. They need scrutiny and they need to be sanctioned. While CVS and other pharmacies are a key part of the distribution network, their leverage in this area is somewhat limited. To begin with, other pharmacies may choose to pick up the rejected business: we're talking big bucks. In addition, CVS at some point will have to disclose the criteria used for rejecting the prescriptions written by certain doctors. Once this happens, doctors may attempt to manipulate their prescription practices to avoid detection and sanction.

In attempting to get its arms around this formidable problem, the State of Florida has reframed the question about who controls controlled substances. While it's apparent that doctors no longer have sole discretion in the area, it remains to be seen how effective and how equitable the control exerted by pharmacies can be. The Insider will monitor with great interest this important experiment in substance abuse control.

We all know that people who smoke and/or are obese tend to have more medical problems, of greater duration, compared to people with healthier lifestyles. The higher medical costs associated with smoking and obesity translate into higher cost for insurance. As a result, it is no surprise that there is a strong trend among employers to charge more for the insurance premiums of workers who smoke or who are obese.

The Insurance Journal writes that the use of premium penalties is expected to climb in 2012 to almost 40 percent of large and mid-sized companies, up from 19 percent this year and only 8 percent in 2009. An Aon Hewitt survey released in June found that almost half of employers expect by 2016 to have programs that penalize workers "for not achieving specific health outcomes" such as lowering their weight, up from 10 percent in 2011. The premium surcharges usually come hand-in-hand with incentives to quit smoking and lose weight. Unfortunately, the carrot of incentives, by themselves, have not succeeded in lowering health costs. Hence the big stick.

Taxing the Poor?
As is often the case, lower paid workers bear the brunt of the higher costs. Obesity and smoking often - but not always - accompany lower income lifestyles. Low income workers already pay a larger proportion of their income for health insurance; now they will pay more for the consequences of their smoking (a formidably taxed bad habit) and obesity (the result of poor dietary habits). The working poor often live in neighborhoods with limited fresh foods and nothing much in the way of health clubs - which they can't afford anyway.

There is evidence that the carrot and stick approach actually works. We have written about the Cleveland Clinic, which refuses to hire smokers or obese individuals and which fosters healthy lifestyles among its 40,000 employees. The clinic has seen medical costs grow by only 2 percent this year, far below the national average of 5 to 8 percent.

The Big "But..."
The move to force people into healthy lifestyles does raise a few interesting issues.
1. In cases where obesity or other unhealthy conditions are beyond the control of the individual (genetics, specific diseases, etc.), the higher premiums might be considered discriminatory, although there has been little such litigation to date.
2. Healthy lifestyles (including regular exercise) may well result in higher medical costs for maintaining well-tuned bodies: the ever-growing incidence of knee, hip and shoulder replacements among active people.
2. The goal is to reduce medical expenses, but the leverage exists only with the principal policy holder: there is no way to force other family members to abide by the lifestyle guidelines.
3. The imposition of wellness standards can lead to legitimate privacy issues: for example, holding employees accountable for behavior away from the job (smoking, drinking, eating).

If all goes as planned, medical costs will indeed come down and people will live longer and longer lives. As people with healthy lifestyles live longer, we will have succeeded in transferring costs from private insurers (who cover working people and their families) to social security (which covers retirees). That will require a hike in social security taxes, which the working poor, among others, can ill afford. It seems that every solution carries the seeds of new problems, just as every problem gives rise to new solutions. It is a privilege, of course, just to watch the entire process as it unfolds before us.

David Williams has posted the In Their Own Words edition of Health Wonk Review over at Health Business Blog - healthcare costs and healthcare reform continue to be vitally important issues to workers' comp. Whither goes the 98% of the health care market, the workers' comp 2% has little choice but to follow. This biweekly digest by professionals, pundits, and practitioners is a good way to keep up on things.

Florida doctors bought 89% of all the Oxycodone sold to practitioners nationwide last year and thousands of outside visitors flocked to the state to buy drugs at the 1,000+ pain clinics. But armed with new legislation, the state is cracking down hard by shutting down pill mills and suspending the licenses of about 80 physicians who were high-volume prescribers. And physicians are now generally barred from dispensing narcotics from their offices. In October, things will get even tougher as a new prescription drug monitoring system will be implemented.

Lizette Alvarez reports on on the Florida pill mill crackdown in The New York Times, stating that "As a result, doctors' purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year." This article has some eye-opening observations about the scope of the prescription drug problem: "Last year, seven people died in Florida each day from prescription drug overdoses, a nearly 8 percent increase from 2009. This is far more than the number who died from illegal drugs, and the figure is not expected to drop much this year."

You can read more about how authorities are going after medical licenses of over-prescribers in a Miami Herald article by Audra Burch. This article discusses some egregious abuses, including a physician who dispenses from the back of a car and an office with long lines waiting outside and many cars with out-of-state license plates in the parking lot.

Related Resources
The issue of physician dispensing is one that our colleague Joe Paduda has covered extensively. See:
Physician dispensing - Exactly how much more does it cost?
Why Florida's work comp costs are heading up
Florida's dispensing legislation clarified

The issue of transparency related to a physician's relationship with pharmaceutical companies is one that ProPublica has been taking on in their Dollars for Doctors campaign. See:
Patients Deserve to Know What Drug Companies Pay Their Doctor
Piercing the Veil, More Drug Companies Reveal Payments to Doctors

For more about Prescription Monitoring Programs, see:
Alliance of States with Prescription Monitoring Programs - The Alliance was formed in 1990 to provide a forum for the exchange of information and ideas among state and federal agencies on prescription monitoring programs. Since then, it has grown to be a valuable resource to all those concerned with combating the increase in prescription drug abuse, misuse and diversion. Currently, 48 states and one territory either have operating Prescription Monitoring Programs, or have passed legislation to implement them.

Health Wonk Review is launching its back to school season with The Hurricane Irene Edition posted by Avik Roy at the Apothecary. If you've been missing your biweekly dose of health wonkery during the abbreviated summer schedule, now is your chance to catch up!

Given the time of the year and the weather, you wouldn't blame our health wonks if there were all lazing around at the beach, but judging by this week's submission, they are all braving the heat and hard at work. And it is hot. It's sizzling outside and on fire in DC as the budget battle heats up and the debt ceiling deadline looms ever closer.

Our wonks are hot too. We kick off this week's edition with Health Wonk Review founder Joe Paduda jumping into the fray. In who passed Part D and why you should care posted at Managed Care Matters, Joe holds some feet to the fire for the deficit.

And before the budget cutting cuts too close to the bone, DC policy makers might consider posts from two of our wonks: At California Healthline, Dan Diamond reports on the recently released Oregon Health Study on Medicaid which some have called the "Most Important Study in Decades" and asks about its potential effect on health reform/health policy discussion. And in the first of a two-part series posted at The John A. Hartford Foundation blog's Health AGEnda, Chris Langston posts his concerns that in the current budget-cutting environment, we may be throwing out the baby with the bathwater with the recent focus on Medicare hospice costs.

While we're dealing with heated issues related to reform, next stop is Health Beat for a post in Maggie Mahar's series on myths surrounding medical malpractice. She deconstructs 7 "myths" which are used to support caps on malpractice awards and looks at the political underpinnings for the push for malpractice reform. She makes the case for meaningful reform under the Affordable Care Act that will achieve a balance of financial carrots and sticks designed to enhance patient safety.

The devil is in the details
As we move deeper into the implementation of the Affordable Care Act, many of our wonks have opinions on its progress. As would be expected on a complex initiative that continues to draw heat, not everyone would characterize the changes as progress.

To start, it can be helpful to look at the way the debate has been framed. Joseph White looks The Mixed (De)Merits Of 'Bending The Cost Curve' at Health Affairs Blog, tracing the development of the phrase. He argues the risks of this now ubiquitous metaphor outweigh its benefits - particularly in how it reflects the dominance of the debate by budgetary perspectives, favoring the interests that benefit from high costs now by devaluing approaches that would reduce costs more quickly.

And in another post at Health Affairs Blog, Tim Jost tackles the proposed regulations for Health Insurance Exchanges in the first of a three part-series of posts. Part 1 introduces the regulation and deals with the exchanges themselves; Upcoming posts will analyze the provisions of the regulations addressing qualified health plans (QHPs) and health insurance issuers (part 2) and the reinsurance, risk corridor and reinsurance regulations issued the same day (part 3).

At The Apothecary, Roy Avik offers a play-by-play replete with video clips of a recent congressional hearing on Independent Payment Advisory Boards (IPAB). Avik's take: "I thought that we had a fairly productive discussion about the ins and outs of Medicare's problems, and IPAB's role in addressing them."

At InsureBlog, Bob Vineyard looks at the numbers for the Pre-existing Condition Insurance Plan (PCIP) and finds them lacking.

Jaan Sidorov of The Disease Management Care Blog suggests that there is one question any hospital board should ask management about participating as an Accountable Care Organization (ACO), which are risk-bearing arrangements.

The Affordable Care Act contains requirements and deadlines for the implementation of electronic medical records, collectively known as Meaningful Use (MU). At Healthcare Talent Transformation, David Scher breaks down the truths and common fallacies associated with Meaningful Use of Electronic Medical Records: A Practical Overview.

Stateside
At John Goodman's Health Policy Blog, John takes a look at the difference that RomneyCare has made. He says that most conservative critics of Massachusetts health reform have focused on any piece of bad news about the program they can find. The thinking has been that if this is the model for the federal legislation everyone calls "ObamaCare" it's got to have a lot of defects, right? But he notes that "The real story coming out of Massachusetts is that the whole thing is a yawner."

Anthony Wright of Health Access Blog says that the real work of health reform is in setting up the Exchanges, and he reports on progress and milestones in the California Health Benefits Exchange.

At Colorado Health Insurance Insider, Louise Norris tell us that in Colorado, the rules are changing for employer funding of individual health insurance. The Division of Insurance's stance regarding the use of Health Reimbursement Account (HRA) funds has changed again, with rules appearing to to have has both relaxed and tightened.

Docs and dollars
Many of our wonks have been looking at the issue of how physicians get paid.

At Health Care Renewal, Roy Poses observes that having the former CEO of a health care corporation that paid more than $1 billion to settle fraud charges as Governor of Florida seems to have led to some interesting investigative reporting. In his post Would You Like Fries With That? - The Fast Food Model for the Corporate Physician he cites a story about the health care corporation with which Rick Scott was most recently associated as an example of what happens when the distinction between physicians and hamburger flippers is blurred.

Do physicians make more money when they treat more complex patients? Jason Shafrin, The Healthcare Economist, examines a recent study in Denmark to see whether this has proven true.

At Health Business Blog, David Williams helps us to understand the economics of health care credit cards for elective procedures: Why do doctors offer credit cards? It helps them avoid discounting

Over at the e-CareManagement blog Vince Kuraitis teams up with Jaan Sidorov to discuss the 100 year shift, in which they see the potential for "a tectonic realignment among physicians, hospitals and payers." In the first of a seven part series, they offer an overview of trends - noting that physicians' economic interests are increasingly aligning WITH payers and AWAY FROM hospitals. Will this result in doctors and payers eventually sitting on the same side of the negotiating table?

Consumer care
At The New Health Dialogue, director Shannon Brownlee makes the case that less is more when it comes to angiograms, the imaging test that precedes an angioplasty or stent. She discusses a report by Grace Lin and Rita Redberg, cardiologists at the University of California, on three focus groups with groups of cardiologists who talked about three hypothetical patients. If your cardiologist recommends you undergo an angiogram, this paper will likely give you a reason to question that recommendation closely.

At HealthNewsReview Blog, Gary Schwitzer has a pair of posts that raise questions about the proliferation of robotic surgery despite questions about evidence for benefits, harms - and costs. One talks about how Wisconsin hospitals with robots double prostate removals within 3 months and a second on the dearth of studies on the effectiveness of robotic surgery - a case of enthusiasm which has not been matched by comparative studies.

At Pizaazz Glenn Laffel makes the case that EMRs can help reduce racial disparities in health care. He discusses why and how Electronic Medical Records can help narrow the digital divide, and calls attention to some vendors who are offering tools to help providers enhance care for medically underserved communities.

At the Improving Population Health blog, David Kindig talks about environmental issues as a factor in public heath in the post Population Health and the Physical Environment: Beyond Air and Water.

Tinker Ready reports and interesting case study of ADA accessibility adaptations that go well beyond Braille and ramps in her post Universal design: The science of access at the Museum of Science at Nature Network Boston - a refreshing story of progress.

Occupational health
Here at Workers' Comp Insider, our focus is generally on the occupational health arena, and we recently looked at whether OSHA's Voluntary Protection Program (VPP) is broken. A recent study points out that several program participants have had multiple fatalities - should they retain their status that allows exemption from programmed OSHA inspections?

That concludes this issue of Health Wonk Review. Our next issue - and final issue of the summer season -- will be hosted at Joe Paduda's Managed Care Matters on August 4.

All other things being equal, if you had a choice of paying $300 or $1800 for an abdominal CT scan just by going to a clinic or a doctor in a nearby town, would you? It seems like a trick question or a no brainer, but the reality is people are paying the higher cost every day... just because the transparency in health care costs just isn't there. And this lack of transparency gives rise to a situation where patients can pay as much as 683% more for the exact same medical procedure in the same town.

More and more people will begin to notice the cost differentials as the trend for consumers bearing increased responsibility for healthcare costs continues. Whether through insurance arrangements such as high deductible plans or through assuming a higher proportion of co-pays and other out-of-pocket costs in more traditional plans, more consumers have a direct stake in the cost of healthcare. Yet the average person with a healthcare insurance policy is in the dark about the costs for various procedures and treatments. First, many consumers have been insulated from the cost of anything beyond the price of the insurance policy itself. The unit cost of services and procedures has largely been a matter between the insurer the provider. Secondly, medical care is a highly complex service with little in the way of tools available for comparison shopping. It's complex enough that even the treating physicians themselves are often in the dark about costs about specific procedures, tests, or medications.

Change:healthcare, a national organization that is trying to establish more transparency in the cost of healthcare, recently released a cost comparison report for several common medical procedures such as MRIs, CT scans, ultrasounds and PET scans. The Q2 2011 Healthcare Transparency Index reports on what they learned about cost variations by examining claims data over the course of a year for 82,000 employees of small businesses. While it's been widely understood and acknowledged that price might vary greatly depending on what part of the country you are in, this study shows that the price can also vary greatly depending on which side of the street you are on: inter-regional costs fluctuate widely, too.

This wild divergence in pricing is probably less of a surprise to employers, many of whom who have been keeping a close and wary eye on skyrocketing workers' compensation medical costs. There are no co-pays or cost sharing mechanisms on the workers comp side of the house - the employer underwrites 100% of the associated costs of a compensable injury or illness. Many enlightened employers have been tackling costs on the macro level (outcomes) as well as on the micro level (unit costs) by seeking high-performing physician networks. But even with the buying power and the resources that a large employer can bring to bear, it can still be difficult to get it right when it comes to managing workers' compensation medical costs.

Whether in work comp coverage or in general health care, many employers have also recognized the role that the individual employee plays in helping to control costs and stem losses - through behaviors both on the job (safety compliance) and off the job (general wellness and healthy behaviors). Wellness and EAP benefits are widespread as a result. In a similar vein with a potential for a win-win outcome, employers should take every opportunity to help employees to become more savvy consumers of health care services.

Here are some consumer healthcare education tools / resources that might be useful in your wellness program:

• Robert Wood Johnson Foundation: Comparing Health Care Quality: A National Directory
• NCQA: NCQA Health Insurance Plan Rankings 2010-2011
• NCQA: Report Cards - online resources to help you choose a health plan or physician
• URAC: Consumer Resource Center - various tools with "information on your rights as a consumer and how to successfully navigate the US healthcare system."
• Foundation for Informed Medical Decision Making - has as its mission "We are working to advance research, policy, and clinical models to ensure that patients understand their choices and have the information and support they need to make sound medical decisions."
• The Dartmouth Atlas of Healthcare - The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians.
• Kaiser Family Foundation: Health Insurance Costs - Consumer Protections

Work can be a killer when workers are asked to do too much: intense labor in the heat of summer, the stress of heavy repetitive lifting, moving too quickly among common workplace hazards. But can work kill us from doing too little? Can work-required inactivity lead to a compensable claim?

For twenty five years, Cathleen Renner worked as a manager for AT&T. With a heavy workload, she often brought work home and labored at her computer late into the night. In September 2007, facing a tight deadline, she appeared to pull an all-nighter; she sent an email to a colleague around midnight and was seen at her desk at 7 in the morning, at which time she complained about a pain in her leg. She labored on through the morning. Around 11 am, she had trouble breathing. By the time she reached the hospital, she was dead from a pulmonary embolism (which began with that pain in her leg).

The New Jersey workers compensation had to determined if work was the predominant cause of the death.

Risks in Doing Nothing
Back in May of 2006, we blogged the dangers of inactivity. If people sit still for a long time - for example, during air travel - they are at risk for deep vein thrombosis. It appears that Cathleen's prolonged and unrelieved sitting at her computer caused just such an incident. According to a medical expert, she experienced an "unorganized" blood clot which developed while she was sitting (as opposed to an organized clot, which takes much longer to form). Despite her other risk factors - obesity and the use of birth control pills - the court determined that her death was work related.

The defense argued that Cathleen lived a relatively sedentary life - that her sitting at the computer was no different than her sitting at other times. But her husband countered with the observation that they had school-aged children. Cathleen was always running around, taking the kids to school and appointments, cooking meals, cleaning the house and doing the myriad tasks that virtually all mothers must perform. That's a pretty compelling argument and it convinced the judges: the Superior Court determined that the prolonged sitting while performing work-related tasks caused her death.

Get Out of that Chair!
Savvy employers will note the risks of prolonged sitting and encourage - require! - employees to get up at least once an hour to move around and stretch. (Policies should cover workers in their home offices, too.) Moving around not only prevents blood clots, it also prevents injuries to the spine. Humans are not meant to sit in one place indefinitely. We are built to move and move we must.

With that being stated, I'm going to stand up and stretch a bit. Unless you are reading this on a treadmill, I recommend that you do the same.

Tinker Ready posts Health Wonk Review: Hockey, hoodlums and hot rod angels at Boston Health News

There's a lot of good reading in this issue - check it out!

Health Wonkery on Twitter
If you just can't wait a few weeks to get the next update of HWR, here are links to some of the HWR bloggers who are active on Twitter:

• Tinker Ready: @tinkerrr
• David Williams: @HealthBizBlog
• Health Affairs: @Health_Affairs
• New Health Dialogue: @NewHealthDialog
• Jaan Sidorov: @DisMgtCareBlog
• Glenn Laffel: @pizaazz
• Incidental Economist: @IncidentalEcon
• Avik Roy: @aviksaroy
• Gary Schwitzer: @garyschwitzer
• Richard Elmore: @richelmore
• Lucidicus Project: @Lucidicus
• Interdisciplinary Nursing Quality Research Initiative: @INQRIProgram
• Brady Augustine: @bradyafl
• Lynch Ryan: @workcompinsider

In the world of workers comp, chronic pain is a major cost driver. When pain persists beyond expected healing times, the prognosis is grim: injured workers suffering from prolonged pain often drift into anxiety and depression and may even become addicted to powerful pain medications. In the downward spiral of relentless pain, it becomes increasingly difficult to separate physical and psychological issues. The prospect of return to work disappears, the injured worker's life disintegrates and the cost of the claim goes through the roof.

The claims adjusters who are responsible for managing chronic pain injuries usually resist any recommendations for psychological counseling; they avoid such interventions because treatment - whether individual or group therapy - cannot and should not be limited to what is "work related." Pain subsumes the worker's entire life. Yet counseling is often an essential part of what is needed: injured workers talking through their many difficulties and sharing their experience with others.

So is it possible to develop a chronic pain program that limits financial exposures, narrows the treatment options and sets reasonable time frames for completing the treatment cycle? And can pain management encompass at least some focused counseling?

A Guide for the Perplexed?
Massachusetts has taken a shot. The state's Department of Industrial Accidents(DIA) Health Care Services Board has issued draft guidelines (PDF) for managing chronic pain. Under the leadership of Dean Hashimoto, who holds both medical and legal degrees, the draft protocol tiptoes through a minefield populated with poppy plants, doctors with prescription pads and long needles, chiropractors, acupuncturists, counselors and biofeed back practitioners - not to mention the ever-present drug salespeople. The draft guidelines could well serve as a Guide for the Perplexed.

Beginning with the caveat that 10 percent of all chronic pain cases will fall outside of the protocol, Hashimoto's task force tries to set parameters for all types of treatment: the number and type of diagnostic and therapeutic injections permissible; the goal-oriented use of mental health counseling, with specified durations (6 to 12 months); "very limited" use of opioid analgesics, with referral to pain specialists, if needed, and including a detailed list of specific actions designed to avoid addiction.

A Work in Progress
The DIA is soliciting comments on these guidelines. Alas, they are unlikely to hear from the relatively small portion of stakeholders who are profiting from the current chaos: the pill-happy doctors, the attorneys who discourage injured workers from returning to work, the physical therapists and chiropractors who believe that treatment, once begun, should go on forever, and the pharma sales folk who encourage use of the most powerful opiates for what is usually short-term pain.

The draft guidelines are comprehensive and reasonable. As the final guidelines will not and cannot have the force of law, they will not eliminate the abuse that currently exists. But if they help motivated treatment practitioners to offer more effective services, and if they open the door to at least some counseling for injured workers, the guidelines will surely save both lives and careers. That in itself will validate the admirable and essential work of Hashimoto's board.

Last month we blogged the suicide of Dave Duerson, a former NFL star who killed himself at the age of 50. In order to preserve his brain for study, he took the unusual step of shooting himself in the chest. He suspected - and the subsequent autopsy confirmed - that he suffered from chronic traumatic encephalopathy, a degenerative and incurable disease that is linked to memory loss, depression and dementia. A definitive diagnosis is available only through an autopsy.

Among the many ironies surrounding this sad tale is the fact that Duerson sat on the six person NFL committee that reviewed claims for medical benefits submitted by retired players. Duerson was known for his harsh line on these claims, apparently voting to deny benefits in many cases (the votes of individual committee members were not recorded). He even testified before a Senate subcommittee in 2007, supporting the NFL's position that there was no definitive relationship between repeated concussions and subsequent dementia.

The days of denial appear to be over. Dr. Ira Casson, who represented the "prove it" mentality of the NFL, is no longer actively involved. The medical evidence is accumulating; while some refuse to connect the dots, it's increasingly clear that repeated brain trauma (concussion) is often directly related to a precipitous decline in brain function in the post-gridiron years.

Old Game, New Order
The NFL is trying to improve the safety of its players. The new rules limiting return to the playing field after a concussion are taking root. Helmet to helmet hits are being penalized with increasing financial severity. But even as the league tries to limit future exposures, the fate of retired players looms large. There will be increasing numbers of claims for disability, including workers comp where applicable, by players who face a substantially diminished burden of proof to connect dementia to playing field ("workplace") exposures.

It is painful to contemplate the agony of Dave Duerson's final days. Confronted with the incontrovertible evidence of his own demise, he must have realized how wrong he had been in taking the company line on dementia. He knew what his own autopsy would reveal: a brain damaged by chronic traumatic encephalopathy, caused by repeated trauma. His choosing to shoot himself in the chest was a farewell gesture, not only to his own life, but to the beliefs that had led him to take a hard line with his former colleagues. A loyal member of the "old guard," he ended his life with the unmistakable and moving embrace of the new order.

Jason Shafrin of Healthcare Economics is hosting the "Opening Day" version of the Health Wonk Review. Jason can be forgiven for his rather bizarre notion of the Milwaukee Brewers winning the World Series, as his line up of health-related articles is first rate.

Go Sox!

In a move stunning for its contrariness, Vermont is moving toward a single payer health care system. In the course of the debate, the inevitable issue of whether to include workers comp has come up. At this point, a committee will make recommendations on whether to "integrate or align" workers comp with the state's radical reconfiguration of the health care system. (Further details are available at WorkCompCentral - subscription required.)

The Vermont approach would completely separate indemnity from medical benefits. Employers would continue to pay for the indemnity portion, but are unlikely to have any input into treatment plans. The Insider has pointed out - ad nauseum, some might say - that the relatively miniscule comp system is quite different from the behemoth health delivery system. In the interests of saving the Vermont committee a little time, here are a few of the conundrums confronting anyone trying to merge the two systems:

: Comp is paid solely by employers. Injured workers pay nothing (no co-pays, not deductibles, ever).
: Consumers pay quite a bit for conventional health coverage: a portion of premiums along with co-pays and deductibles for treatment and for medications
: Comp has very narrowly defined eligibility requirements, while conventional health has virtually none
: The goal of comp is to provide medical treatment for injured workers and, if possible, return them to work; if return to work is not possible, comp pays lost wage benefits and injury-related medical bills virtually forever.
: The goal of the conventional health system is to take care of people, regardless of the employment implications
: Comp provides indemnity, temporary or permanent, for those unable to work. No such wage replacements exist in the conventional health system
: Perhaps most important, medical services under comp have an occupational focus, with the explicit goal of returning people to their jobs. In the conventional health system, any occupational focus would be subordinate to the goals of the consumer.

Should Vermont achieve its ambitious goal of universal coverage, the presumption is that everyone would have a primary care physician, who would serve as gatekeeper for all medical services. (Let's set aside, for a moment, where the Green Mountain state will be able to find these primary care doctors.) In a unified system, injured workers would go to their primary care physicians for work-related injuries. These primary care docs may or may not focus on returning their patients to work. Many people hate their jobs and might welcome a few weeks or months of indemnity-supported leave. The primary care physician might be quite sympathetic to their cause.

This brings us to the great divide between conventional health care and workers comp: conventional health care may or may not embrace the need for return to work. Indeed, if the work is hazardous - as much work is - the doctor may want to discourage his patient from returning to it. The doctor's goal is to "do no harm" - so why send someone back into harm's way? If the patient suffers from lower back problems and has a job involving material handling, what is the right thing for the doctor to do?

Who Pays?
In the current system, workers comp pays doctors for eligible medical services. Whether or not they like the comp fee schedules, doctors are acutely aware that comp is paying for the services of a particular individual. Often, treatment is provided by occupational specialists, who bring a unique "return-to-work" focus to the treatment plan. These occ docs are often in communication with employers seeking to return injured workers to productive employment. The occ docs specify the restrictions so that employers can design appropriate modified duty jobs. The employers have a sense of urgency, as they are losing the productivity of the individual who is out of work - and of course, they are paying all of the costs associated with the injury.

Under the proposed Vermont system, all bills will be paid the same way. Comp disappears from the doctor's view. Employers may have little input into the choice of doctors or specific treatment plans. The role of occupational doctors is unclear, to say the least. Given that primary care physicians generally lack an occupational focus, return to work may become secondary to the comfort and personal inclinations of the patient. As a result, there is a risk of substantial increases in indemnity costs.

When contemplating change on the scale of Vermont's single payer system, it is tempting to brush aside the implications for something as small as the workers comp system. That would be a big mistake. The system might be small, but the costs to the state's employers are already substantial and have the potential for going much higher. The comp system plays an unique and long-established role in protecting both workers and employers. As they take steps to transform healthcare in Vermont, lawmakers need to remember that workers comp itself is worthy of their protection.

Dr. Trang Nguyen has some serious doubts about the effectiveness of spinal fusions, especially in workers comp. In his study of 1,450 cases of chronic lower back pain in the Ohio comp system, Dr. Nguyen focused on an outcome near and dear to the hearts of all comp practitioners: the number of injured workers returning to the workplace after surgery. The results of his compelling (if less than purely scientific) study, published in Spine Magazine, are cause for alarm.

Dr. Nugyen looked at cases involving chronic back pain that were at least two years old, divided equally among workers who had spinal fusions and those who did not. Among those with fusions, only 25% returned to work, compared to 66% among those who received conservative (non-invasive) treatment such as physical therapy.

That is a huge differential. In addition, 27% of the fused workers had to undergo a second surgery, and as any claims adjuster can tell you, doubling up on spinal surgery places workers on a downward slope toward failed back syndrome: permanent total disability. Among the fused workers, 11% were permanently disabled, compared to only 2% among those who avoided surgery. Finally, most of the workers who underwent fusions were still on strong opiates two years after the treatment. In other words, they still suffered from the pain that led them to treatment in the first place.

While this is not a definitive study, the findings surely offer a cautionary tale not only for workers who suffer from back pain, but for their families and employers as well. It is no great mystery why fusions have become the treatment of preference for so many medical specialists. One doctor used the analogy of giving out hammers: people with hammers - surgeons who can do fusions - look for nails (people who might need the treatment).

Something for the Pain
We are an impatient culture. When in pain, we want immediate relief. Given time, appropriate medications and the skilled hands of physical therapists and chiropractors, the pain usually goes away, or at least reaches more tolerable levels. To be sure, there are severe injuries when fusion is the necessary option; however, pain alone is not an indicator of such severity. The problem with fusion is that it creates rigidity in a part of the body that is designed for flexibility. A rigid spine is an open invitation to lifelong pain and despair.

From the comp perspective, we should remain aggressively sceptical of most proposed spinal fusions. Claims adjusters should routinely require a disciplined utilization review, an objective second opinion and an independent medical exam. Place a strong burden of proof on any doctor proposing fusion for an injured worker. Fusion should be the treatment of last resort.

These are not merely delaying tactics. Rather, they are essential strategies for buying precious time, time for the natural healing process to take place and time to avoid what often becomes a path to oblivion. If, as this study shows, the odds for return to work are more than double for workers receiving conservative treatment, then it is in everyone's best interest to avoid fusion surgery. Refuse to Fuse. That's a motto worth posting over the desk of every comp adjuster in America.

As long as we're on the topic of healthcare today, it seems to be an opportune time to share a moving video clip that we bookmarked over the holidays. Marty Ratermann, a Missouri a craftsman and furniture maker, relates his story as a cancer patient at the 2010 Health Literacy Missouri Summit. He was diagnosed with Stage 4 rectal cancer in 2008. After a grueling recovery process, he has been in remission for more than a year. He details how his situation could have been prevented with better communication between him and his doctors.

His story illustrates the difficult path that a person faces navigating the complex healthcare system and making critical choices at a point when he or she is particularly vulnerable. His prescription at the end of the clip is a simple one: take the time and make it a priority to communicate.

I couldn't help but think of the parallels in the healing process for workers who have experienced a serious injury. Many a claim has spiraled out of control for want of good, clear communication and a simple human-to-human moment of concern. So often, we see workplace injuries that are treated as financial transactions when, in reality, they are fundamentally human events: someone is injured, often through no fault of their own. The complexity of the system a worker may find themselves suddenly thrust into, the unfamiliar insurance jargon, the impersonality - all occurring at a point where the worker may be feeling fear and anxiety about their future physical and financial well being. Our prescription: Less thinking about the injured worker as a claimant and more thinking about them as a person. In our experience, that's what leads to the best financial outcomes in the long run.

A Patient's Story from Health Literacy Missouri on Vimeo.

It's Health Wonk Review day - the first issue of the new year after a holiday hiatus. Avik Roy of the Apothecary hosts "Health Wonk Review: Should Auld Acquaintance Be Forgot?" edition. With the healthcare debate again front and center, it's a timely issue highlighting many of the controversies. Check it out.

The folks at American College of Occupational and Environmental Medicine (ACOEM) know something about doctors. They also know quite a bit about workplace injuries in that most of the members are physicians actively practicing in the field, in one capacity or another. That's why we sat up and took notice when we saw their recent publication, A Guide to High-Value Physician Services in Workers' Compensation - How to find the best available care for your injured workers. ACOEM joined forces with the International Association of Industrial Accident Boards and Commissions (IAIABC) to produce the 11-page "best practice" summary, which includes the best thinking and contributions from a diverse group of workers' compensation system stakeholders in a meeting convened by ACOEM and the IAIABC last April. You can see the list of participants on page 11 - a group of heavy hitters that includes a geographical and industrial sampling. It's great to see a think tank of employers and insurers sitting down at table with policymakers and physicians to come to some agreement about best practices. The only thing we might suggest for improvement would be to add a representative from labor at any future convocations.

The stated purpose of the document is to provide specific guidance and resources to all stakeholders in the workers comp system - from injured workers and employers to insurers and TPAs - to help identify the best physicians for care of both everyday, uncomplicated injuries, as well as for specialized medical services addressing catastrophic injury or administrative tasks required by the workers' compensation process.

It identifies ways to find physicians who:

• Are willing to accept patients covered by workers' compensation insurance
• Employ best practices in providing high quality and compassionate medical care
• Respect and fulfill the extra responsibilities that the workers compensation system creates
• Produce better overall outcomes at comparatively better total cost over the course of an injury or illness. (High-quality care produces better outcomes for workers and better value for payers.)

The Guide offers both a "High value" checklist and a step-by-step process for identifying physicians, verifying credentials, working with, and measuring performance. We put this one on our "required reading" list. And for adjunct reading, we also recommend ACOEM's Preventing Needless Work Disability by Helping People Stay Employed.

Friday afternoon in August - who wants to be too serious? We think it's the perfect time to deploy the secret stash of medical-humor related videos we've been collecting,

The first is a feel-good clip performed by staff at Providence St. Vincent Medical Center in Portland, Oregon to raise awareness for breast cancer.

The next clip is a Gilbert & Sullivan parody created by the Neuroscience Education Institute to be a little video played at the beginning of lectures presented by Dr. Stephen Stahl.

The Model of a Psychopharmacologist

The third clip is performed by the Laryngospasms, a group of practicing Certified Registered Nurse Anesthetists who create and perform medical parodies for audiences throughout the United States.

Other gems
The Colorectal Surgeon Song - OK, this is not performed by actual medical folk, but well worth a listen anyway!

UAB Emergency Room Tap - created by ER nurses for a National Nurses' Week contest and celebration. UAB nurses and other staff members are featured in the video.

Breathe - another ditty by the Laryngospasms. More can be found at www.Laryngospasms.com

Footloose: Nursing School Style - Baylor Louis Herrington School of Nursing cuts footloose.

Like much of the country, we've had a sizzling summer here in the northeast, and we are just entering the dog days of summer. In Ancient Rome, the Dog Days extended from July 24 through August 24 and were popularly believed to be an evil time "when the seas boiled, wine turned sour, dogs grew mad, and all creatures became languid, causing to man burning fevers, hysterics, and phrensies."

That sounds like a pretty accurate description of the climate as we head on into election season. If you thought all the excitement over health care reform had died down and you could slack off for your summer reading, think again. Things are still pretty heated and we expect much in the way of sea boiling, wine souring, madness, phrensies and hysteria right through the November election. To help you make sense of things, our esteemed contributors offer up an assortment of hot issues related to healthcare - from costs and reform to technology and ethics.

In A Reply to the Cato Insitute Report, Part 1 Maggie Mahar of Health Beat takes on Michael Tannner's 52-page thesis Bad Medicine, which asserts that the Patient Protection and Affordable Care Act is both unaffordable and unfair. Bad Medicine is meant to serve as a playbook for those who hope to kill reform, a theme that Tanner says will serve as the "centerpiece of Republican campaigns this fall."

In his post Controlling health care costs: Who's responsible?, Joe Paduda of Managed Care Matters wonders why those who believe health reform is socialism don't have faith in the free market's ability to control costs and deliver quality.

Uwe Reinhardt of Health Affairs Blog contemplates the difference between widgets and health care as he examines the issue of whether more insurers will better control health care costs.

In Standardizing Payments for Childbirth, Louise of Colorado Health Insurance Insider offers a quick and dirty summary of her idea to lower the c-section rate, which would be one piece of the 'costs' puzzle that is overwhelming our healthcare system.

David Williams of Health Business Blog expresses doubt about the sincerity of Republican objections to sending extra money to the states for Medicaid, but just in case, he offers a suggestion for how the deficit hawks can satisfy their concerns about Medicaid spending.

We have a pair of posts from the bloggers at Health Access WeBlog. First, Anthony Wright notes that the rate hikes by Anthem Blue Cross of California that helped jump-start health reform have had a second, third, and fourth act. He thinks that their recent rate filing demonstrates that public scrutiny matters. Next, Beth Capell reminds us that reform isn't just about expanding coverage - it's also about saying adios to the junkiest of junk health insurance.

A final rule for the "Meaningful Use" Regulation for Electronic Health Records has recently been issued, and two of our regular contributors shed light on the topic. Rich Elmore at Healthcare Technology News delivers a compendium of resources and analysis related to the final rules for Health Information Technology - Meaningful Use and Standards/Certification. David Harlow of HealthBlawg explains how this rule, along with the EHR certification rule and the HIPAA rule amendments (also recently released) will govern the future development of health IT in this country, and discusses details and implications of the meaningful use rule.

In his posting The Medicare 'doc fix': How to make political lemonade, Austin Frakt of The Incidental Economist, says that the Sustainable Growth Rate system was flawed from the start and should have been fixed years ago, but now we have an opportunity to make necessary systemic changes.

Jaan Sidorov of Disease Management Care Blog says that although the risk may appear to be low, Congress should consider the risk of a physician boycott of Medicare. He suggests that good business practice -- Enterprise Risk Management (ERM) -- requires it.

In Whose costs? Our costs, The Notwithstanding Blog suggests that patient convenience as a benefit of medical care delivery is largely ignored, and he makes the case for why it is a factor that should be weighed in any honest evaluation of competing reform proposals.

Peggy Salvatore of Healthcare Talent Transformation advocates for E-learning as the most cost effective and best way to educate healthcare workers on the use of IT in her post Technology for Healthcare Education: Build it and They Will Come, and Keep Coming!

Jared Rhoads of the The Lucidicus Project has been tweeting about the highlights and lowlights of the healthcare chapter of Mitt Romney's book, "No Apology: The Case For American Greatness." He's compiled his tweets in his blog post: Twead #3: Mitt Romney. (Here's a Twitterspeak Guide for all you non-tweeters)

Media Matters
In Everybody outta the pool!, Henry Stern of InsureBlog reports on a new high risk health pool and suggests that an agenda-driven press has mangled the message.

At Healthcare Economist, Jason Shafrin observes that when Congress enacted the Medicare and Social Security programs, the media coverage was intense. He notes, however, that Medicaid's beginnings were more humble.

Ethics and marketing
Roy Poses of Health Care Renewal posts that the Avandia spin cycle continues even after the FDA safety hearings, noting that the case offers a good lesson in the need for skepticism about data and claims proffered to support commercial health care products. He finds it particularly disappointing that formerly prestigious medical societies and disease activity groups are increasingly funded by industry, and increasingly act like industry marketers.

Tinker Ready looks at the ethics of advertising, questioning whether hospitals should be promoting drugs used in clinical trials as "treatment" in her post MGH: Research as Marketing? at Nature Network Boston. We usually see Tinker at Boston Health News but this post appears the forum/blog/calendar/jobs site for local scientists.

Extended reading
In a series of posts (#1; #2; #3; #4; and #5), Brad Wright takes a closer look at health reform by elaborating on quotes drawn from Brown University political science professor Jim Morone's Health Affairs article Presidents and Health Reform: From Franklin D. Roosevelt to Barack Obama."

Over a series of posts at The Apothecary, Avik Roy discusses a Medicaid study from the University of Virginia which suggests that Medicaid patients fare worse than the uninsured (and far worse than those with private insurance) when undergoing a broad range of surgical procedures. Roy also points to posts by Incidental Economist Austin Frank, who has a different take on the studies.

In the the following guest post, Gary Anderberg, Phd, the Practice Leader For Outcomes and Analytics at Broadspire offers his thoughts on the potential impact of healthcare reform on workers comp in the coming years.

At the moment, health care reform appears to have a number of positive and negative potential impacts on workers compensation over the next few years. The net results cannot be estimated this early in the game. We can, however, identify a few elements and their possible consequences:

• Insuring the now uninsured: Positive -- employees who have health insurance tend to file fewer workers compensation claims. They have less incentive to cost shift. Another result will be that chronic medical conditions will be, over time, better controlled and less likely to increase the severity of work related claims.
• Availability of care: Negative -- with a large number of people having new health coverage, doctors and facilities may be swamped in some areas. The problem will lead to (a) delays in appointments for workers compensation-related medical treatments and (b) less willingness by providers to participate in occupational medical networks and offer discounts off fee schedules.
• Removing the pre-existing exclusion: Unknown -- in 2014 the pre-existing exclusion will disappear in group health. This cuts several ways at once. There will be less incentive for employees to claim long standing "wear and tear" conditions as work related - a positive change. There may also be much greater demand on employers for workplace and job accommodations leading to new exposures and safety issues.
• Medicare reform: Negative -- the passage of HR 3590 was predicated on massive adjustments in Medicare reimbursement levels, which are marginal for medical providers now. This will pressure providers, especially hospitals and some specialists, to cost shift where possible and workers compensation is a soft target in most states. We could see significant increases in medical costs per claim as the Medicare changes begin to bite in a couple of years. (The recession-driven cutbacks in state Medicaid reimbursements will only amplify this effect in the near term.)
• Libby care: Unknown -- the "Libby care" clause of HR 3590 (sec 1881A) is not intended to lead to the federalization of industrial diseases absent some very specific catastrophic circumstances comparable to those of the WR Grace disaster in Libby, MT. But we all know that ERISA was intended to address a very narrow set of union pension abuses when it was passed, but the Department of Labor, abetted by the Florida Administrators decision of the Supreme Court in 1977, expanded it greatly. The Libby care provision will bear watching.

With a population around 1.5 million and a land mass the size of New England, Idaho is probably not the first state that comes to mind in the national struggle to contain medical costs. Nonetheless, orthopedists in Idaho have managed to attract the attention of the federal government in their effort to increase rates of reimbursement for services. The feds are not happy with the Idaho docs.

The first problem came with the workers comp fee schedule. The "Resource-Based Relative Value system" set a price of $88 for most orthopedic procedures. The 65 or so orthopedists in Boise got together and decided to refuse to treat workers comp cases. As a result, the Industrial Commission raised the rates by 61 percent. Score one for the docs.

Emboldened by their success, the docs refused to accept Blue Cross patients under the prevailing fee scheme. But in taking on the conventional health care (as opposed to the state-based workers comp system), the docs crossed a line from a program run exclusively by the states into a behemoth system in which the federal government plays a big role. The feds came down hard with charges of violations of the Sherman Anti-Trust Act. Prosecutors sued five doctors, the Idaho Orthopaedic Society and the Idaho Sports Medicine Institute in Federal Court. If you think about it, it's not hard to see how a bunch of doctors agreeing to hold out for higher reimbursements might fall under the general heading of "price fixing."

As we have blogged rather frequently, Massachusetts has the lowest fee schedule in the nation. Most orthopedists have responded by refusing to accept the (ridiculously low) rates. But unlike the orthos in Idaho, the MA docs deal with the palty rates on their own. By refusing to accept them, they compel insurers to negotiate higher rates. These negotiated rates vary from doctor to doctor. There is simply no way and no need for the hundreds of orthopedic doctors in MA to agree on rates:it would be like the proverbial herding of cats.

In Idaho it's different. The state's unique characteristics - the large land mass and relatively small population - make a genuine "conspiracy" possible. The docs all know one another. So what seemed to them a fairly innocent attempt to leverage the system for higher reimbursement rates appeared to the feds as a conspiracy. In other words, their mistake was in sharing information about the rates and in uniting to take action against them. Had they acted individually, there would have been no violation of the anti-trust act.

War on Docs?
One blogger with roots in the libertarian Ludvig Von Mises movement sees in the government action a declaration of war against doctors. He believes that doctors will be "forced" to accept the government rates. Not exactly. As we have seen in Massachusetts, individual doctors can accept or reject patients as they please. What they cannot do is collude with fellow doctors to achieve a fee schedule to their liking.

With rising medical costs looming over every aspect of our economy, this little skirmish in Idaho is simply the opening salvo in what is likely to be a prolonged and painful battle to contain the costs of health care. It's no accident that the Obama health care bill punted on the cost containment issue. One person's cost containment plan is inevitably another's cut in pay.

In the coming months, the battle of Idaho will move into the great metropolitan areas of our country. Just imagine the formidable barricades to be erected by the men and women in blue scrubs! This will be an interesting brouha, to say the least.

We've compiled a variety of resources on the health care reform developments this week:

First stop, see Joe Paduda's excellent analysis of Health Reform's implications for workers' comp, part 1, part 2 and part 3. Joe's expertise in the inner workings of the medical side of workers comp make this a must-read.

In the National Underwriter, Arthur D. Postal gets insurer reactions to bill passage: Insurers Decry Health Bill for Lack of Cost Restrictions

Insurance Journal looks at the various suits filed by 12 state Attorneys General which challenge the constitutionality of reform: How States Are Responding to Healthcare Reform Law and Republican Attorneys General Pursue Sovereignty Claim Against Health Bill

Law Professor Mark D. Hall, J.D. offers his thoughts on the constitutionality of mandating health insurance at The Health Care Blog.

At the Washington Post, Ezra Klein explains how the exchanges work. Also see How big is the bill, really?

Jaan Sidorov at Disease Care Management Blog Has a multi-part post focusing on What the Health Reform Bill Says About Prevention, part 2

Tinker Ready does a local roundup over at Boston Health News: Health reform: How's it playing in Mass?

At Healthcare Economist, Jason Shafrin samples the international reaction.

At Gooznews, Merrill Goozner talks about the the reinvention of social progress and notes the Physician Payments Sunshine Act, which requires more transparency about payments that drug and device companies make to doctors.

For employers, Anne Freedman of Human Resource Executive suggests that uncertainty reigns. While most changes for employers won't be in effect until 2014 to 2018, she outlines some changes that go into effect this year.

Consumer Corner
The New York Times Prescription blog answers reader questions on the Health Care overhaul -

At Kaiser Health News, Phil Galewitz offers a Consumers Guide to Health Reform. Kate Steadman and Julie Appleby talk about the immediate effects of the Health Reform Bill.

The Washington Post offers a cost calculator to help consumers learn the impact on their situation: What does the health care bill mean to me? -

Specifics about the legislation - from House Speaker Nancy Pelosi's page

U.S.A. Today looks at how health care overhaul affects taxpayers.

Three months ago we blogged the ongoing agony of Bath Iron Works (BIW), the people who build destroyers for the navy. You may recall that BIW self insures for workers comp, and as such must pay the "usual and customary" fees for medical services provided to injured workers. There are only two categories of payers who are stuck with usual and customary fees: self insureds and uninsureds. BIW has been waiting 18 years for Maine to come up with a fee schedule. Eighteen years! The Board in charge of developing the fee schedule is asking for...a little more time.

So what's the problem? Paul Dionne, the Chairman of the Maine Workers Comp Board - the board responsible for developing the fee schedule - is also board chairman of Central Maine Healthcare Corporation - which stands to lose a lot of money once the fee schedule is implemented. Dionne is compensated by the comp board and by Central Maine Healthcare. If he were really candid, he might admit that his idea of a fee schedule is "usual and customary" fees. Dionne claims they are really getting close to the point where they will be able to issue a draft fee schedule for public comment.

Timely Remedies?
As reported by Lindsay Tice in the Lewiston Sun Journal, BIW has filed suit, claiming that Dionne has a conflict of interest. This is their second lawsuit. Back in 2006 they sued the board for its (then) 14 year failure to implement a fee schedule. The judge sided with BIW and ordered the board to create the fee schedule. Four years later...well, you get the drift (and I do mean drift!).

Dionne has consulted with an attorney, who advised him that there was a "potential" for a conflict of interest. (Brilliant work, counsel!) Dionne is seeking a second opinion from the board's general counsel. Here's a second opinion: it's a conflict of interest!!!

Dionne claims that, if necessary, he will fully disclose his personal interests, as he has done in the past. Sure, Paul. The foxes are promising better management of the chicken coop. Foxes love chickens. They are very committed to raising the "usual and customary" chickens, fat and healthy.

Start Over?
The sheer passage of time, now approaching two full decades, has compromised the Maine fee schedule beyond recognition. It has become an embarassment. It's unlikely that any fee schedule issued by this board will be credible. Perhaps it's time to create a truly independent body to develop the fee schedule. The bad news for BIW is that this would further delay the regulatory relief they have long sought. The good news is that the fee schedule might actually lower the fees.

During this prolonged process, BIW has tumbled down the rabbit hole, Maine version, into a world where nothing is quite what it seems. BIW - in the unlikely role of Alice, meets a cheshire cat, with a grin like Paul Dionne's:

`Cheshire Puss, ...Would you tell me, please, which way I ought to go from here?'
`That depends a good deal on where you want to get to,' said the Cat.
`I don't much care where--' said Alice.
`Then it doesn't matter which way you go,' said the Cat.
`--so long as I get SOMEWHERE,' Alice added as an explanation.
`Oh, you're sure to do that,' said the Cat, `if you only walk long enough.'

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.

In Greek mythology, Daedalus built the Labyrinth for King Minos of Knossos to contain the awful half bull/half man Minotaur. Theseus eventually killed the Minotaur, but only found his way out of the Labyrinth because Ariadne had given him a magic thread to mark his way in and out of the maze. I'm beginning to think that American health care makes the Labyrinth look like an easy walk across Boston Common on a sunny day. And, so far at least, no one seems to have found the magic thread.

Workers' compensation medical care is now getting whipsawed by two powerful and unstoppable forces: the Medicare Secondary Payer Statute (MSP) and the inexorable aging of the baby boomer generation.

We've written about these two looming catastrophes in the past. Seventy-eight million baby boomers are hard to ignore, and the MSP issue is starting to remind me of the 1958 horror movie, The Blob , wherein a gelatinous creature grew gargantuan by eating everything in its path. Two things have already occurred in the new year that bode well for continued growth of the MSP Blob.

The insurance industry goes a-begging
Last week the American Insurance Association, the National Association of Mutual Insurance Companies and the Self-Insurance Institute of America wrote to the Department of Health and Human Services Secretary Kathleen Sibelius asking her to delay the 1 April 2010 implementation of MSP mandatory reporting requirements. You can find the reporting requirements here.

The new regs lay a heavy burden on the comp insurance industry, referred to in the regs as Responsible Reporting Entities (RREs). (Such unfortunate acronyms bring me back, alas, to my days in the military.) RREs must report to the Centers for Medicare and Medicaid Services (CMS) any workers' compensation claims that involve ongoing medical payments, with the exception of most medical only claims. In their letter, the organizations list five reasons they believe an implementation delay is necessary. The first items are all about process: security protection, a lack of guidance from the CMS and an insufficient period for testing the proposed reporting procedures. The fifth reason, which is really the first reason, is the economic big stick which, when deadlines are missed, will slap fines of up to $1,000 per day per claim upside the heads of RREs. Ouch!

There's a lot more to it, and we'll be writing more about it in the coming months, but for now it's enough to know that the insurance industry is on its collective knees asking for a delay in the implementation of reporting requirements that have already been delayed and extended once.

Inedible Maryland Crabcake?
The second thing affecting MSP that happened in the new year may or may not turn out to be a big deal. On 4 January 2010, the Maryland Workers' Compensation Commission issued emergency regulations that require CMS approval for all workers' compensation settlements, not just the ones that meet the review thresholds in the CMS User Guide, version 2.0. The commission is requiring CMS review of virtually every claim up for settlement.

The new procedures require that every settlement pass through CMS before the Commission will approve it. Here is an excerpt from Maryland's emergency regulations:

A settlement that falls within the Medicare thresholds must be approved by CMS before it will be approved by the Commission.

A settlement the falls outside the Medicare thresholds may be approved by the Commission provided that the settlement agreement:

1. Contains a statement confirming that the interests of Medicare have been considered in reaching the settlement; and

2. Identifies the amount of the proposed settlement:

a. Apportioned to future medical expenses;or

b. Set-aside for future medical expenses through a formal set-aside allocation

3. The apportionment of the amount of the settlement associated with future medical expenses shall be supported by medical evidence such as a medical opinion or evaluation.

While it remains to be seen if the Commission's action will significantly delay settlements or increase costs in Maryland, it's reasonable to assume that it will. As any workers' compensation professional knows, the longer a claim stays open, the more it costs. As a result, the Maryland approach to Medicare set asides is not a good candidate for replication in other states.

A Magic Thread
As I write this, I'm about to leave for San Antonio for the 2010 Health and Productivity Forum, sponsored by the Integrated Benefits Institute and the National Business Coalition on Health. I'll be participating in a panel discussion organized and led by Broadspire's Gary Anderberg, one of the smartest people I know. Our panel will be addressing workers' compensation medical care and costs and the effect health care reform may have on both. I sure hope that Gary has brought a few spools of Ariadne's thread. We're going to need some magic to guide us through this formidable labyrinth.

My colleague Julie Ferguson raised some fascinating issues relating to the growing movement to approve marijuana as a medication. As is so often the case, the implications for workers comp diverge substantially from general health issues. A toke may be just what the doctor ordered for pain management, but in the context of the workplace, any such prescriptions are likely to preclude actually reporting to work.

Here are just a few reasons why the use of medical marijuana is incompatible with the workplace:
- I cannot think of any job suitable for a person who is experiencing a marijuana high (actuaries? Just kidding)
- You cannot operate a motor vehicle or any piece of equipment safely while under the infuence of marijuana
- Imagine the impact on co-workers when a fellow employee lights up a joint. ("Note from a doctor. Yeah, right! By the way, who is your doctor?")
- Smoking is prohibited by law in virtually all indoor workplaces. "Accommodating" a marijuana smoker by allowing him/her to light up outside of the building raises issues for co-workers and the general public, not to mention the police.

It will be very interesting to see how strongly state legislatures step in to protect medical marijuana users. As Julie pointed out, no state is currently requiring that employers offer "reasonable accommodation" in this situation; it is unlikely that any will do so. The day may come when marijuana makes the list of approved medications in the workers comp system, but prescriptions for weed are unlikely to be accompanied by a return-to-work release from the doctor.

Medical marijuana, along with alcoholic beverages and prescribed opiates, may be legal substances, but employees under their influence do not belong in the workplace. Employers should place the burden of proof squarely on the shoulders of the treating doctor, who must be able to certify in writing that the prescribed use of pot does not put the employee, co-workers and the public at risk for injury. Quite frankly, unless someone works from home, I don't see how this burden of proof can be met. When it comes to performing a job safely, any toke is a toke over the line.

Hines Ward is the epitome of the NFL tough guy. As a wide receiver for the Pittsburgh Steelers, he is known for his flamboyant personality and his ability to give and take ferocious hits. He was the most valuable player in Superbowl XL. In his pursuit of athletic excellence, he is a gambler. No, he is not betting on games. He is betting with his own life.

In the course of his football career, Ward has suffered numerous concussions. But he continues playing. He has even lied about his symptoms, so that the doctors would allow him to keep playing.

In this regard, Ward is part of the mainstream culture of professional athletics. Play today, pay (perhaps) tomorrow.

Until recently, the NFL was complicit in allowing players like Ward to gamble away their futures in the interest of the next game. The league's leading advisor on concussions, Dr. Ira Casson, routinely dismissed every outside study finding links to dementia and other cognitive decline, including three papers published by the University of North Carolina’s Center for the Study of Retired Athletes.

The NFL is in the midst of a major change of policy regarding concussions. Dr. Casson has resigned. The league is requiring teams to have an independent consulting neurologist examine players with concussions. They have finally acknowledged what has been obvious for years: repeated concussions, especially when occuring over a relatively short period of time, can have a devastating effect on the brains of athletes. Well, duh!

Roethlisberger Sits, Ward Frets
Hines Ward came face to face with the new, more cautious NFL this past weekend, when star quarterback Ben Roethlisberger sat out a crucial game against the Baltimore Ravens. He suffered a concussion the prior week, when his head collided with the knee of an opposing player. Even though he practiced with the team all week, Big Ben suffered from recurring headaches toward the end of the week. At the last minute, the coach kept him from the game and substituted a relatively inexperienced quarterback. The Steelers lost.

After the game, Ward said the Steelers players were split 50-50 on whether Roethlisberger should have played. Ward added that, “these games, you don’t get back.”

“I understand what the league is doing,” he said. “I don’t judge another man.”

He went on to say: “We needed him out there. We wanted him out there. This is the biggest game of the year. We lost and we kind of dug ourselves a hole. Me being a competitor, I just wish we would’ve had all our weapons out there. It’s frustrating.”

Paradigm Shift: Sudden or Gradual?
The NFL will never be for sissies. Nonetheless, the policy shift on concussions is long overdue and most welcome. However, it may not be easy to enforce. Players like Ward may soon learn to remain silent on critical symptoms (dizziness, headache). They may avoid talking to the team doctors so they can stay in the game. These old school tough guys might even call out teammates who choose a more cautious route. As the legendary coach Vince Lombardi supposedly said: "Winning isn't everything. It's the only thing."

Well, not quite. There are many things in life that are a lot more important than winning. Just ask one of the many retired NFL players with Parkinson's or dementia.

In the conventional workplace we tend to fret about people with minor injuries, who may resist returning to work even though it is safe to do so. In professional sports, it's usually the opposite: athletes will do almost anything to get back into the game, even jeapordize their future health. Just as we could use a little more of a "get me back in the game" attitude from reticent employees, we need to recognize that concussions require time to heal. Toughness is fine in its place, but let's not be stupid about it. A game is just a game, a job is just a job. Neither is worth a single life.

Given the discouraging and often appalling level of debate on health insurance in America, it was refreshing to view the PBS Frontline broadcast “Sick Around the World,” a documentary that dispassionately analyzed different health care systems from five developed countries: Britain, Japan, Germany, Taiwan and Switzerland. The program originally aired during the presidential campaign of 2008, but, given the current country-wide debate regarding health care, PBS executives thought a re-broadcast would be appropriate, and they were right. You can view the entire program online here: The veteran Washington Post foreign correspondent, T.R. Reid, wrote and hosted the program. After the program aired, Reid kept working on the global health care issue, and in August, 2009, Penguin Press published his new book, The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care.

Neither his Frontline program nor his book have the vitriol or cynicism of Michael Moore’s “Sicko,” which Reid suggests did a good job of showing what is wrong with America’s health care system, but a poor job of showing what is good (and bad) about health care in other nations. In Moore’s piece, any other health care system is in every way better than America’s. Reid does not make that mistake. He just lays out the facts and lets the viewer or reader come to easy conclusions.

At Lynch Ryan, we’re vitally concerned about American health care, both personally and professionally. Personally, because we believe that high-quality health care is a basic and essential right for all Americans; professionally, because nearly 60% of workers’ compensation losses are spent on medical treatment. Workers’ compensation is the tiny caboose at the back of the great big American health care train. In March, 2008, I published “The Best Health Care in the World” as a series of essays in our Workers Comp Insider. In it, I tried to compare health care in America with that of the rest of the developed world, the other twenty-nine countries that make up the Organization for Economic Cooperation and Development (OECD).

In Sick Around the World, T.R. Reid cites the same statistics I did, but focuses on five countries within the OECD that have systems different from America’s and mostly different from each other. However, unlike America, each of them has universal health care and achieves results that are better and cheaper, sometimes far better and cheaper, than ours.

Britain
First, he examines Britain, the system most Americans who don’t know any better like to belittle, but whose population has somehow managed to have a life expectancy that is two years longer than ours. Reid treats the British system with great respect. Why? Because as a reporter he lived there, and his family routinely used the National Health Service. He found the care exemplary and never paid a dime for it. It’s a government owned and operated system, and all prices are set by the government. And, lest you think that it would be intolerable in America, you should know that it is exactly the system used by our Veterans Administration. Year after year, the VA significantly outdistances the private health care sector in patient satisfaction, as measured by the University of Michigan’s American Customer Satisfaction Index . Patient satisfaction in the private sector has been increasing over the last few years and has a current score of 77 out of 100. The Va’s 2008 scores, on the other hand, are 89 for retirees, 85 for inpatients and 81 for outpatient clinics. And at 3% administrative costs, the VA provides quality medical care much cheaper than any other health care program in America.

Japan
Next, Reid traveled to Japan where the population lives five years longer than ours, 82.1 versus 77. Somehow, despite those mortality figures, much longer hospital stays, three times the number of CT Scans and 30% more MRIs per capita than in the US, Japan spends only half as much of its GDP on health care as we do: 8% compared to a whopping 16%. Japan uses a “social insurance” system with citizens either getting insurance through their employers or through community-based non-profits. The average family monthly premium is $280, and employers pay more than half. Costs are kept down, because every two years the government negotiates the price of every singly procedure, something our congress refuses to allow. Moreover, there are no gatekeepers; the Japanese can see specialists whenever and as often as they want, and waiting periods are insignificant. Finally, because Reid also lived and worked in Japan for years (he even speaks the language), he once again offered the personal perspective regarding the high satisfaction he and his family experienced within the Japanese health care system.

Germany
After Japan, Reid wandered to Germany, the country with the very first “social insurance” system, created by Otto von Bismarck, the Iron Chancellor, in the mid-1880s. Germany’s citizens live two years longer than ours, and the German infant mortality rate is about half that of the US, yet the country spends less than 11% of its GDP on health care. The average family premium is $750 per month, but premiums are pegged to patients’ income. Germans buy insurance from one of 200 non-profit “sickness funds.” Co-pays are about $15 paid once every three months. The “funds” cannot discriminate in any way; for example, through pre-existing conditions, age, demographics, medical history, etc. Germans like their system, although doctors, who are paid only about two-thirds of what their American counterparts make, would like to earn more. However, malpractice insurance is a non-issue and many doctors attend medical school for free, obviating any need to repay a huge school loan, as most US doctors must do.

Taiwan
Staying in Asia, Reid hopped a plane for Taiwan. Why Taiwan? Because its system was created from scratch in 1995, only 14 years ago. Prior to that, the Taiwan health care system was third-world at best, but in the late 1980s and early 1990s its economy grew, propelling it into the ranks of wealthy nations and giving the country the chance to build an entirely new health care paradigm. The Taiwanese were very systematic in designing their health care program. They hired Harvard Professor Bill Hsiao to examine and analyze all of the systems in the rest of the developed world (Why can't we get guys like that?). On his recommendations the government then crafted a sort of smorgasbord of a National Health Insurance plan, although, fundamentally, it’s based on the Canadian system. Every citizen has to buy insurance, but there is only one insurer, the Taiwanese government. This keeps premiums down to about $650 per year for a family of four. Employers split the cost of the premiums with their workers. Where the Taiwanese really excel, however, is in their embrace of technology; it’s a paperless system, because every citizen has a “smart card,” which stores medical histories and bills the government insurer for services. Like America's VA, the entire country is on an electronic medical record system, and that is one of the big reasons that Taiwan manages to achieve excellent health care results while spending only 6.3% of GDP on health care. Admittedly, when you’re creating something from next to nothing you don’t have to go to war with rich vested interests; there are none.

Switzerland
And that’s why Reid went to Switzerland. Prior to ten years ago, the Swiss health care system closely resembled America’s, warts and all. Not only that, Switzerland is home to a lot of insurance and pharmaceutical companies. But a decade ago, the Swiss had an epiphany: they decided that quality health care is a basic human right, and the country’s elected officials decided to redesign the system, which they concluded was discriminatory and costly. It wasn’t easy. They faced many of the same arguments that now float over and suffocate America. Ten years later, the Swiss still have, per capita, the second most expensive health care system in the world, but it’s still 25% less than America’s. They have achieved universal health care coverage. Insurance premiums are $750 per month for a family of four, paid entirely by consumers, but the government subsidizes low income citizens. Insurers cannot make a profit on basic care and have to accept everyone. They negotiate prices with doctors, but the government sets the price of drugs.

Home Again
In America, health care plays a significant role in about 50% of bankruptcies. When Reid was interviewing ministers from each of the five countries, he asked if anyone in their countries ever went bankrupt because they couldn’t afford health care. They were aghast at the thought. It could never happen, they said. And none of them could understand why it would be allowed to happen in the world’s richest country. Neither can I.

In America, health care has become a commodity, market driven enterprise. Throughout the rest of the developed world, it is an essential human right; something governments were created to provide and protect. In America, legend and myth influence many of our citizens, who feel that any government intrusion into health care will lead to draconian tactics typical of a fascist state. They don’t seem to realize that our Veterans Administration health care, treating millions of our veteran heroes every year, is a direct copy of Britain’s. Or that Medicare, our largest insurer with more than 36 million members who, in poll after poll, report high satisfaction with their health care, is modeled on the health care system of Canada.

Maybe our American health care house that Jack built, what T.R. Reid calls a “badly fragmented crazy quilt system,” is just too big to be redesigned into something we could all be proud of. But when I’m tempted to say, “A plague on all their houses,” I think of the Taiwanese, who went from nothing to one of the most technologically advanced, yet inexpensive, health care systems in the world in just fourteen years. And I think of the Swiss, the bureaucratic, economically driven Swiss who have come to see high-quality, affordable health care as the absolute right of every Swiss citizen. If these two totally different countries can do that, I ask you, why can’t we?

In all of our discussions about controlling the cost of workers comp, we continually come up against two lifestyle issues that have a direct impact on costs: obesity and smoking. Let's leave obesity for another day and focus on smoking.

According to a compelling article by Stephen Smith in the Boston Globe, 70 percent of smokers want to stop, but fewer than 10 percent will succeed each year. For non-smokers, this might appear to be a matter of will. But that is both condescending and a gross over-simplification.

Nicotine, the primary addictive agent in tobacco, steals into the brain, setting on fire circuitry that regulates our sense of pleasure [emphasis added]. At the same time, cigarettes acquire a sort of social permanence in smokers’ lives - a way to start the day, to end a meal, to celebrate good times, to muddle through bad times.

Smith uses a rather terrifying analogy to describe how nicotine enters the brain:

Smoking is a uniquely efficient manner of delivering an addictive substance to the brain. “That’s why crack cocaine is so much more addictive than regular cocaine,’’ said Dr. Nancy Rigotti, chief of Massachusetts General Hospital’s tobacco treatment center. “Cigarettes are kind of like the crack cocaine of nicotine.’’

Inhaled nicotine from a cigarette arrives in the brain in 10 seconds. There, it attaches to an especially pivotal region of neurons, those cobweb-like structures that govern our physical and mental actions.

Nicotine, said Dr. Jonathan Winickoff, a tobacco control researcher at Mass. General, “stimulates the same area that get stimulated when you have a wonderful gourmet meal or when you have sexual intercourse. It lights up that part of the brain, which is the rewards center. It drives human behavior. It’s powerful stuff.’’

Hmm. Similar to gourmet meals and love making. No wonder people have trouble walking away from the habit, despite the known and often dire consequences of continuing to smoke. It would take powerful medicine indeed to counteract nicotine's overwhelming appeal.

If there is good news in all of this, it is that a combination of drug therapy and counseling increase the chances of success.

“The data are very clear that you can double your chances if you use a medication if it’s appropriate for you, and you can triple your chances if you use a medication and counseling,’’ said Thomas Glynn, director of cancer science and trends at the American Cancer Society.

The medicine cabinet now includes seven first-line treatments, anchored by five forms of nicotine replacement. Regardless of the delivery system, the goal is to stave off the withdrawal symptoms and cravings that bedevil so many people who want to quit.

Finally, perseverence is key. You just have to keep at it.

“It takes smokers seven to 11 quit attempts to quit for good,’’ said Lois Keithly, director of the Massachusetts Tobacco Control Program. “We need to get the message out that if you make a quit attempt and you relapse, you don’t give up.’’

Smoking Out Smokers
It will be interesting to see if the nation's pending experiment with universal health care attempts to tackle the issue of smoking. Will smokers be charged higher premiums? (With a significant portion of smokers qualifying for premium subsidies, such penalties may prove difficult to enforce.) Will the new insurance rules mandate coverage for smoke cessation programs, including the full range of pharmacology options plus counseling? On the one hand, the success rates are low, so smokers are likely to keep smoking; on the other hand, any and all successes project to future cost savings.

Let there be no doubt about how hard it is to give up cigarettes. After all, we have the image of our president: a self-possessed, calm and extremely bright (American born!) man sneaking out of the White House for secretive puffs. Good luck to him and to all smokers who strive valiantly to give up this nasty habit once and for all.

We live, alas, in interesting times. As the health care debate spirals downward, the fault lines in our culture become more and more evident. On one side, anti-reformers stack town meetings to prevent any meaningful dialogue from taking place. These folks are even trying to intimidate unions. What am I missing here? Who is supposed to intimidate whom? On both sides of this momentous debate, pockets are being stuffed with special interest money. This makes the ultimate outcome - whether status quo or some degree of reform - highly suspect. The notion of genuine debate and civil discourse have disappeared altogether.

Which leads us back for a moment to the lingering conflict between UPS and FedEx. Back in December, we blogged FedEx's unusual charter:

FedEx began 35 years ago as an airline. As such, it fell under the Railway Labor Act of 1926, which made unionization of public and commercial transport companies extremely difficult. By contrast, UPS began as a trucking company and was subject to the National Labor Relations Act from day one. UPS is unionized: they pay workers more than FedEx, they provide better benefits.

It would be to UPS's advantage to remove their fierce competitor from the Railway Labor Act and force them to operate under the NLRA. That requires an act of congress, so it's no surprise that UPS has been aggressively lobbying congress for this change. They say they want to level the playing field.

Level playing fields are fine. The devil is in the details: how do you accomplish your goal? Apparently, by playing unfairly. UPS has been accused of forcing union members to write to their congressmen, urging passage of legislation to eliminate the FedEx exemption. The letters bombarding congress appear to express the views of individual UPS drivers. In fact, many are based upon prescribed forms. We read in the Washington Post:

Officials with UPS and the International Brotherhood of Teamsters, which represents 240,000 UPS drivers, acknowledge that the company has paid for workers' time to pen many of the letters and has supplied the envelopes, paper and stamps needed to mail thousands of them to Congress. UPS spokesman Malcolm Berkley said the effort was "totally voluntary, and any allegations to the contrary are ridiculous."

But Internet sites dedicated to UPS-related discussions feature dozens of accounts from anonymous employees who in recent weeks have said they were forced to write the letters or felt they would be punished for not doing so. Such tactics could run afoul of both labor laws and lobbying disclosure requirements, according to legal experts.

So it appears that UPS may be violating labor laws in order to force FedEx to operate under labor laws. Were you expecting anything different?

Images
In one of Norman Rockwell's many iconic images, a humbly dressed man stands up in a town meeting to express his opinion. The painting is entitled "Freedom of Speech." We could certainly argue the degree to which such freedoms ever existed. But it's all too clear that Rockwell's image bears no relation to what is occurring today. If he were to depict our present situation, we would see an enraged citizen shouting down his local congressman. This individual would waive an inflammatory poster complete with Nazi symbols. In his pocket, we might glimpse the bus ticket that brought him into town. In the corner we might see an innocent mother, huddling to protect her child from the pending violence.

We are currently facing many complex issues, ranging from FedEx's status as an employer to the health care options for every American. There are pros and cons to every path. No one really knows how to get from point A to point B. Indeed, we may not even agree on what point B is. But when civil discourse deteriorates into the ravings of the mob, we all lose. If winning is defined by who shouts the loudest, who cheats the most effectively, who succeeds in intimidating the oppostion, there will be no victory for anyone.

Over the last twenty years, medical costs have gradually, but steadily, replaced indemnity wage replacement as the engine driving the workers' compensation train. This is the same period during which our nation's health care costs have grown from average among OECD countries (Organization for Economic Cooperation and Economic Development) to double the average (PDF). In other words, workers' compensation medical cost increases reflect similar increases within the general public. The only surprising thing here is that during the last decade or so, the steady increase in workers' compensation medical costs has happened at twice the rate of those eye-popping group health increases.

The National Council on Compensation Insurance (NCCI) has convincingly demonstrated that the rise in workers' compensation medical costs is due primarily to over-utilization of physical medicine services, especially those for chronic, soft tissue claims. (See here (PDF) and here (PDF ). And now, Atul Gawande, writing in the June 1, 2009 issue of The New Yorker, has demonstrated even more convincingly that over-utilization of medical services, including testing, surgery and hospitalization, is the metastasizing cancer in America's health care system.

Dr. Gawande's lengthy article, The Cost Conundrum, for which he should win the Pulitzer Prize, is the most trenchant argument yet for why costs in America are so appallingly high, but outcomes merely mediocre. He reduces the problem to its simplest terms. In essence, our American health care house that Jack built has turned the once noble profession of medicine into nothing more than assembly line piecemeal work, and our physicians both in primary care and the specialties, have been economically incentivized to over-prescribe in all areas. And, as Gawande's article clearly shows, the areas of the country that produce the highest costs with all that over-prescribing also produce the poorest health care results.

Dr. Gawande examines health care in McAllen, Texas, a town within Hidalgo County, the County with the lowest household income in the country, but, after Miami, the second most expensive health care costs. He wanted to know why. He also wanted to know why health care costs in El Paso County, eight hundred miles to the north with similar demographics to Hidalgo’s, were 50% lower.

He wanted to know why the Mayo Clinic, in Rochester, Minnesota, with the best medical technology on the planet, produced some of the highest quality medical care in the nation, but with costs that rank in the lowest fifteen percent of the nation. And why the Mayo was able to replicate that achievement when it opened its hospital medical center in Florida, one of the country’s highest cost states for health care?

His answer? Because in the pockets of excellence he found around the country doctors work together in teams, peer-reviewing each other's work. In these low-cost, high-quality areas, physician income is neutralized. At the Mayo, for example, the doctors are all on salary. Whether they order ten procedures or none, they get paid the same. This is central to understanding how to fix the problem. As Gawande writes:

"Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country's best electrician on the job (he trained at Harvard, somebody tells you) isn't going to solve this problem. Nor will changing the person who writes him the check.

This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here's how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some "skin in the game," and then they'll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care."

The Cost Conundrum, by Atul Gawande, should be required reading for anyone interested in understanding and participating in American health care reform. And that should be all of us.

For the last 3 or 4 years, I've been privileged to be a Trustee at Commonwealth Care Alliance, a Massachusetts non-profit HMO serving dual eligible elderly poor. In this case, "dual eligible" means people who qualify for both Medicare and Medicaid. CCA does great work, but it's always swimming upstream. It gets reimbursed by increasingly low and lower Medicare and Medicaid payments. And let's face it, the elderly poor do not constitute an influential political constituency.

One of CCA's founding Board members is Rob Restuccia. In the early 1990s, Rob founded Health Care For All (HCFA), a non-profit health care think tank and advocacy organization devoted to creating a "consumer-centered health care system that provides comprehensive, affordable, accessible, culturally competent, high-quality care and consumer education for everyone, especially the most vulnerable." You see, Rob believes health care is a basic human right, not a privilege for those who are lucky enough to be able to afford it -- a position with which I wholeheartedly agree. HFCA was a central player in the successful effort to pass the Massachusetts Health Care Reform Plan, which, to date, has brought health care to 97.4 percent of its citizens. Universal coverage is a reality in Massachusetts, albeit a more expensive one than originally thought.

The founders of HCFA and its public interest and very influential law firm, Health Law Advocates, are the alumni who came out of the Dukakis Administration and who continue, with lance in hand, to attack the biggest windmills they can find, and, as the Massachusetts Commonwealth Connector proves, those lances are still sharp.

Rob now runs Community Catalyst, a powerful, grass-roots, national non-profit, active in more than 40 states and dedicated to bringing affordable, quality health care to everyone in America. You've probably never heard of it, but I assure you that the dealmakers on Capital Hill are well-aware of Community Catalyst.

As I have written before, health care within worker' compensation, at only two to three percent of total health care spending, is the tiny caboose on the back of the great big group health locomotive. But workers' compensation medical costs have increased at roughly twice the rate of group health annual increases for a dozen or more years, and most experts agree that the biggest engine fueling the constantly rising comp medical costs is over-utilization, which itself is driven in large part by a lack of coordinated care.

Rob Restuccia's Community Catalyst has just published a white paper on Coordinated Care, Special Delivery: How Coordinated Care Programs Can Improve Quality and Save Costs. This paper does not focus on coordinated care within workers' compensation. Its logically larger aim is to influence care in the other ninety-seven percent of medical spending. However, the absolutely common sense points it makes and lessons it preaches can, and I suggest, should be applied to the world of workers comp.

It deserves to be read by everyone involved in the current health care debate.

Joe Paduda has posted this week's Health Wonk Review: Health Reform - what's happening and why. It includes analysis and commentary from our usual participating policy experts - as well as guest commentary from Senator Byron Dorgan (D ND), chair of the Senate Democratic Policy Committee, who gives us his thoughts on the importance of reform and a window into the process.

Other news
Three workers were killed and more than 40 were injured in this week's devastating explosion at the ConAgra meat plant in Garner, North Carolina. According to medical authorities, several of the workers are being treated for burns covering 40 percent to 50 percent of their bodies; other suffered exposure to toxic fumes from ammonia leaks. Teams from the Bureau of Alcohol, Tobacco, Firearms and Explosives, the U.S. Chemical Safety Board and the Department of Labor have been dispatched to the site to begin investigations into the cause of the explosion. Via WRAL, survivors recount their experience. More on the explosion: The Pump Handle and Comp Time

NIOSH addresses health and safety issues related to green jobs, noting that "...for the product of work to be truly sustainable, the work itself must also be sustainable. It must protect not only the surrounding environment and its end-users, but also the workers who are producing it. Sustainability must include worker safety and green jobs must be safe jobs."

National Underwriter reports on a potential federal regulatory plan for insurance, which may be unveiled next week. Related: In this month's Risk Management, Lori Widmer asks if now is the time for the optional federal charter. For more background, see the Insurance Information Institute: Optional Federal Charter.

If health care reform is the proverbial 800 pound gorilla, then the medical portion of workers comp is a 15 pound Maine Coon cat: it might big for a cat, but compared to a giant gorilla, it is barely noticeable. Nonetheless, this cat is blessed with a very strong notion of what it needs. As the nation moves closer to universal health care, the implications for workers comp are both profound and troubling. Comp medical services comprise a mere 2% of total medical expenditures, so policy makers in Washington will be inclined to ignore its special needs. That could create profound problems for the employers, insurers, and state administrators who deal with comp issues.

There are a number of key reasons why reform of health care may undermine the ability of states to deliver a quality workers comp system. (We previously blogged these issues here, here and here.) In order to provide some focus for the pending debates, here is a brief summary of how comp fits into the overall medical universe:

The focus is similar but not identical
The general health care system focuses on the prevention of what can be prevented and the treatment of that which can be treated, up to limits of coveraged defined in specific health plans. The overall goal is to preserve the life and health of individuals and families. This system provides treatment from conception up to the moment of death.
The comp system has a much narrower focus: comp provides treatment only to workers who are in the course and scope of employment. Comp treats work-related injury and illness, with the specific goal of returning injured/ill workers to productive employment.

Eligibility is Radically Different
The general health system provides defined services to individuals and families. Virtually any illness or injury is covered, including many forms of mental illness.
Comp covers only what occurs during work and is proven to be work-related, with an almost phobic disregard for mental impairments.

The cost structures are very different
In general healthcare, the premiums for coverage are paid by individuals and their employers. Depending upon the plan, individuals and their family members assume at least some of the cost of treatment, through premiums, co-pays and deductibles. The trend has been to shift more and more of the costs onto the consumer (which, in turn, becomes an incentive to reduce utilization).
In comp, employees never pay comp premiums and are never charged co-pays or deductibles. Injured workers are covered from the first dollar. Thus, only the employer, self-insured or who purchases mandatory coverage, and the insurer have the incentive to control costs. No such incentive exists for injured workers.

There are Perverse Incentives in the Comp System
Under comp, injured workers are paid not to work (indemnity). They may not like their jobs. They may malinger, seeking treatment more often than medically necessary (no co-pays to discourage them), thus prolonging disability in order to avoid work. The incentives for returning injured/ill employees to work lie primarily with the employer (who pays the premiums or is self insured) and the carrier (who pays the bills, which may exceed the premiums collected).

For employees with minimal job skills and perhaps no job to return to, the incentive for remaining on comp as long as possible is powerful.

Comp is a State-Based Program
The new mandates for health insurance coverage will come from the federal government. Comp, by contrast, is strictly a state by state program. The new federal mandates (eg., employee choice of doctor) may well conflict with long-established systems.

Policy makers are trying to create a new paradigm for medical coverage in the twenty first century: truly, a daunting task. Ultimately, the new direction for health care will be driven by cost and coverage. Whether the providers are public, private or both, health care cost controls and rationing will lurk in the shadows: will there be a cap on total expenditures for any given individual and any given conditions? Will there be limits on end-of-life services? How much of the costs will be shifted to consumers? What incentives will be created to reduce utilization?

In stark contrast, comp is and will remain an early 20th century system, based upon an industrial world that no longer exists. It already provides virtually universal coverage for people who work. The costs belong exclusively to employers and carriers; there is no cost-shifting onto injured workers and there are no incentives for these workers to limit expenditures. The over-arching goals are returning injured workers to productive employment and providing lifetime benefits for the totally disabled.

So it all comes down to this: When and if the 800 pound gorilla that is universal health care actually sits down, will it be beside - or on top of - the comp coon cat? Will the federal mandates take into account the unique and idiosyncratic needs of the comp model, or will the new mandates inadvertantly crush the system, state by state by state?

There are often unintended consequences when well-intentioned humans try to solve gargantuan problems. Let's hope that the comp system does not fall victim to this fundamental law of human endeavor.

Our blog last week linking skin cancer to workers comp has already generated a few comments. "Workers comp attorney" raises some interesting questions:

(1) How much weight do you give to the person's leisure activities and/or length of employment? It seems these would certainly be factors in assessing whether the employment is the predominate cause.
When assessing the work-relatedness of skin cancer, claims adjusters will look carefully at non work exposures: hobbies such as hiking, fishing, boating, outdoor sports, surfing, swimming or simply tanning. Balanced against these exposures will be the work setting: outdoors all the time (eg, roofing, migrant farm work, paving) or just incidentally (framing carpentry).

While the case law is still rather limited, there are examples of compensable skin cancers involving a limousine chauffeur (!) in New York and an architect in Texas. [NOTE: a sun screen manufacturer, unsurprisingly, is keeping close track of case law developments!] It is safe to assume that the burden of proof remains on the employee to show that the cancer is work related, but this burden is now supported by substantial medical evidence. Indeed, the existence of government funded education on the risk - here is a CDC link - would tend to support claims of compensability.

As far as length of employment goes, it usually does not matter. As in the case of repetitive motion injuries, the most recent employer is usually on the hook for coverage, even if the employee has only been working for a few weeks.

(2) What steps could employers take to prevent work-related skin cancer other than the mentioned provision of sun screen and policies to enforce dress code?
Employers should just stick with the basics: provide - and enforce the use of - sun screens; require head gear. In the vast majority of exposed workers, this is not happening. There is research showing an increase in skin cancers among Latinos. I wonder if this is related to the negative cultural images associated with protective gear. [NOTE: my teenage daughters hate my wide-brimmed sun hat. It's just not cool!] [I wear it anyway.]

(3) What about research indicating that some, if not all, sunscreen products are carcinogenic?
While there is some evidence that tanning booths may be associated with cancer, I am not aware of any medical evidence to support a connection between sunscreens and cancer. In any event, the risk of not using a sunscreen far exceeds the risk of using one.

4) What balance should be sought between skin cancer and heat-related illnesses (if any "balance") as far as prevention is concerned?

Skin and heat protection are not mutually exclusive. People have been covering up in desert cultures for centuries by wearing light colored, loose clothing and head gear. (I hardly need add that American workers would vehemently reject any protective measures that made them resemble middle-eastern sheiks!)

Proactive, Reactive, Inactive?
Another reader wonders how many companies have actually implemented the recommended preventive measures. That's a great question. Judging by limited observation of workers in the sun, smaller employers have done little if anything to prevent risk. Any time I see a worker in the hot sun, shirtless and hatless, I assume that the cancer issue is simply being ignored.

What, if anything, will mobilize employers to take action to limit sun exposures? It usually comes down to money. Employers who operate in states that view skin cancer as potentially work related will eventually find it cheaper to provide (inexpensive) sunscreens and hats to their workers in the great outdoors. If state courts reject these claims, the workers will bear the burden.

Let's hope that employers take action before the courts force the issue. We have a known risk and we have proven remedies. Reason says that employers, at a minimum, will immediately share this information with exposed workers. But then again, how often is the voice of reason heard in the American workplace?

The Mercury News offers some potentially bad news for California employers. After four years of comp reform, with rates dropping a staggering 63 percent, the trend is now headed - perhaps precipitously - in the other direction. The Workers' Compensation Insurance Rating Bureau is requesting an increase of 24.4 percent, due mostly to sharp increases in medical costs. The gist of the editorial is simple: we need health care reform in order to tame workers comp costs in California (and, presumably, the nation).

Most people would agree that reform of conventional health insurance is needed. There are millions of people without coverage across the states and the number is growing by the minute. But the relationship of any such reform to the cost of workers compensation is by no means linear. As we saw during the aborted attempt at health care reform during the Clinton administration, solving one problem (access to health care) might well create others (soaring costs for workers comp).

The Deciders
In conventional health insurance, treatment decisions are made primarily by doctors and patients, along with the patient's family. Insurance carriers review the decisions to make sure they are within treatment guidelines. There are two fundamental sticking points: insurer approval for exotic, untested treatments (lots of push back here) and insurer approval for expensive drugs/treatment protocols (push back here as well).

The decision process in workers comp has one additional over-riding factor and one additional party: the factor is the goal of return to work (which may or may not be the goal of conventional healthcare); the additional party is the employer, who is paying the bills (either as a self-insured or through the experience rating process for comp premiums).

The Mercury News assumes that solving the health care problem will naturally solve the comp problem at the same time. This may not be the case. The medical portion of workers comp has a unique and relentless focus: returning injured workers to productive employment as quickly as possible. Under conventional health care, this goal might seem simplistic or even counter-productive: the workplace might aggravate the health problem, in the form of repetitive movements, physically demanding tasks, toxic exposures or even stress. In some circumstances, caring physicians will hesitate sending their patients back into these compromising situations. Where occupational medicine assumes that return to work is almost always a positive goal, family medicine may differ.

Comp Is DIfferent
The medical portion of workers comp is only 2 or 3 percent of total health care costs, so it will be tempting to ignore the comp factor as new national health policies are developed. This would be a mistake. Unless policy makers are prepared to undo nearly 100 years of workers comp protection, they must take into account comp's unique benefit structure, which includes lower cost of treatment for workers, the involvement of the employer in decision-making, and indemnity payments during the period of disabilty. For injured workers and their families treatment under comp is always cheaper than treatment under conventional health plans, because there are no co-pays and no deductibles in comp. In addition, treatment decisions for work-related injuries include input from the employer, who is generally not a participant in conventional health care decisions. Finally, comp offers a virtually universal indemnity plan for injured American workers; they are paid during the period they are unable to work.

Comp requires a special focus. Even if policy makers succeed in achieving universal health care for all Americans, they will not necessarily solve - indeed, they may aggravate - the problem of rising costs for workers comp.

As Washington tackles the problem of health care for Americans, the Insider will continue to focus on the policy implications for workers comp. It's a small piece of the puzzle, to be sure, but one of paramount importance to us.

It was only a matter of time before the perfect storm hit state employee healthcare. It happened this week, on August 20, in, of all places, Alabama.

By 2011, Alabama employees who are obese, hypertensive, or have high cholesterol or high blood glucose will have to pay $25 more each month for their state health insurance. In 2010, they’ll pay $25 more if they haven’t enrolled in wellness programs to address their health risks.

Alabama has 37,555 active state agency employees covered by the State Employee Insurance Board. In the last ten years state health care costs for these workers have risen 172%. As yet untouched by the new rules are the 222,445 active duty and retired teachers covered by a separate system – the Public Education Employees Health Insurance Plan, but one suspects their time will come. After all, their health care costs have risen 200% in the same period.

To put this in perspective, consider this. Since 1999, Alabama health care and pension costs for all employees, including active and retired teachers, have risen 241%. But state revenues have risen only 67%. When one factors into the mix that:

• Only two states in the nation have more overweight people than Alabama, and that
• 43% of Alabama’s state employees are overweight, and that
• 19% are extremely overweight with body mass index greater than 35, and that
• Medical costs for the extremely overweight are $1,700 a year higher than for employees of normal weight (body mass index less than 25), and that
• Current economic indicators do not suggest a rapid rise in state revenues over the next few years, but that
• Health care annual costs are expected to continue increasing at double digit rates, then
• It doesn’t take much of a genius to conclude that as time goes by the situation becomes more and more untenable, hence,
• The unveiling and rapid descent of the economic Hammer of Thor.

Notwithstanding that, obesity is the big killer. As I wrote in a monograph on The Best Health Care in the World that debuted here in the Insider as a 5-part series in March of this year:

Unfortunately, obesity has been shown to be a greater driver of health care and health care spending than alcohol consumption or smoking – "the effects of obesity are similar to 20 years of aging." According to Thorpe, et al, 27% of the per capita increase in US health care spending between 1987 and 2001 was attributable to obesity. There is a direct correlation between obesity and Type 2 diabetes, obesity and hypertension and obesity and heart disease (the trends in obesity accounted for more than 38% of the increase of diabetes spending and more than 41% of the increase in spending on heart disease since 1987).

Although one can hardly say that Alabama is noted for leading the national way, one has to ask, "As Alabama goes, can the nation be far behind?"

We have seen that America spends more on health care than other developed democracies around the world for outcomes that, on the whole, are no better than those achieved by the average OECD country. Our health care "system" perpetuates ever-increasing spending without delivering results to justify the expense. Moreover, because of our country's isolation, both geographically and culturally, few Americans actually know about or appreciate this disparity. In the words of that eminent philosopher, Pogo, "We have met the enemy, and he is us."

But not all the news is gloom and doom. We lead the world in medical technological innovation, and we have chosen to target this expensive technology at some very thorny problems. Further, statistics don't always tell the whole or true story. Sometimes, one needs to lift up the rug and check what's lying underneath.

Take infant mortality, for example.

The best place to find infant mortality data is (drum roll): the US Central Intelligence Agency, which tracks the rate of infant deaths in 241 countries around the world in its World Facts Book.

Currently, the CIA shows Angola, with 184 deaths per 1,000 births, as having the highest infant mortality rate (IMR) in the world, 241st out of 241. That is, more than 18% of Angola’s infants die shortly after birth. In fact, with the exception of Afghanistan, the 24 countries with the world's highest infant mortality rates are all in Africa. It has long been known that IMR directly correlates with a nation's per capita GDP.

At the other end of the scale, Singapore, a high-GDP country, ranks first, with the world's lowest infant mortality rate – 2.3 deaths per 1,000 births, followed by Sweden, Japan, Hong Kong, Iceland and France.

And where in this mix is the United States you may ask. Well, with a rate of 6.37, we rank number 41 in the world.

Or do we? It all depends on how one treats the numbers, because not everyone defines infant mortality the same way. The most common definition is: the number of deaths of infants, one year or younger, per 1,000 live births. The question is – what is a live birth? The World Health Organization (WHO) defines a live birth as "any born human being who demonstrates independent signs of life, including breathing, voluntary muscle movement, or heartbeat." However, the United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. And the US is far more aggressive and advanced in attacking and treating significant neonatal complications. Visit any major teaching hospital's neonatal ICU and you’ll see what I mean. The inference is that the US’s actual comparative infant mortality rate may actually be lower, perhaps much lower, than is statistically reported.

But those neonatal ICUs cost a lot of money. It’s an investment the US has chosen to make, unlike most other countries, and it is symptomatic of why we spend so much more than the rest of the world on health care.

Of course, if you spend a few minutes talking with a mother and father who have just brought a young child home, healthy and smiling, after six months, of so, in one of those expensive, neonatal ICUs, you might be excused for thinking, as they surely do, that the cost is worth every penny.

Prior entries in this series:
Part Three: What Do We Get for the Money?
Part Two - What does it cost?
Part One: The best Health Care Plan in America

In Part One of this series, we began looking at some of the many cost disparities between group health and workers' compensation.

In Part Two, we compared US health care costs with costs in the other 29 member-countries of the Organization for Economic Cooperation and Development (OECD). OECD countries, all democracies, are considered the most economically advanced in the world. We saw that health care spending in the US is a breathtaking 250% greater than the average for all of these developed democracies. Moreover, as measured by Gross Domestic Product (GDP), health care made up 15.3% of the US economy in 2004 - up from 5.1% in 1960 - nearly double the rest of the OECD.

Today, it's time to examine what we're getting for all that money. It seems fair to ask a few questions relative to the other OECD countries:

1. Do we live longer?
2. Are we healthier?
3. What other factors could affect how the health of US citizens compares with OECD citizens?

Do we live longer than people in other OECD countries?
Simply put, we spend a lot more on healthcare than all other OECD countries, but don’t live any longer for the money. In fact, we live shorter lives than most.

As of 2004, average life expectancy at birth in the US was 77.5 years, which ranks 22nd out of the 30 OECD countries. While this is slightly below the OECD average, it is four and a half years less than top-ranked Japan. Also, it may surprise readers to learn that life expectancy is two and a half years longer among the people of our neighbor to the north, Canada. And, despite all the editorial bashing of the UK's National Health System, its citizens outlast us by a full year, while people in Spain, France, and Italy live, on average, more than two years longer than we do.

Are we healthier?
For all the money we spend on healthcare one would think we enjoy Olympian health, but this does not appear to be the case. Although it pains me to write this, I can find no peer-reviewed studies that conclude that we are a healthier people than our OECD neighbors.

The OECD provides specific disease incidence data in two areas: cancer (malignant neoplasms) and acquired immunodeficiency syndrome (AIDS). In both cases, the US has the highest rates in the OECD. The incidence of cancer in the United States is 34% higher than the average within the OECD (358 cases per 100,000 people versus 266). With respect to AIDS, the US incidence is an astonishing 675% higher than the rest of the OECD (147 cases per 100,000 people versus 19 in the OECD). Our mortality rate due to AIDS ranks second in the OECD (4.2 deaths per 100,000 people, well behind the staggering rate of 8.6 in Portugal). Yet our mortality rate for cancer ranks only 14th among OECD countries.

What about obesity, reputed by many to be epidemic in the US? With the exception of the UK and the US, which get their obesity statistics by actually measuring people, OECD countries get their results from surveys, so the only fair comparison is the US versus the UK. In 2004, while the UK's overweight population was 14% higher than that in the US, our obese population was 39% greater.

On the other hand, the US rate of alcohol consumption and incidence of daily smoking were both lower than the average for OECD countries (daily smoking in the US is the third lowest (17%) of all OECD members).

Unfortunately, obesity has been shown to be a greater driver of health care and health care spending than alcohol consumption or smoking – "the effects of obesity are similar to 20 years of aging (PDF)." According to Thorpe, et al, (The Impact of Obesity on Rising Medical Spending (PDF), Health Affairs, 20 October 2004), 27% of the per capita increase in US health care spending between 1987 and 2001 was attributable to obesity. There is a direct correlation between obesity and Type 2 diabetes and obesity and hypertension. Is it any wonder that in the last thirty years Type 2 diabetes and hypertension have seen explosive growth in the US?

What other factors could affect how the health of US citizens compares with OECD citizens?
There are many other factors that have been identified as influencing how the health of Americans compares with the rest of the OECD. Some of these are:

1. The age of our population – While this will be a concern in the immediate future as baby boomers grow older, currently 12% of the US population is older than 65, which is below the OECD average of 14%.

2. Income and insurance – The US is unique in the OECD, because it does not have a national insurance program. About 60% of us are covered by some form of employer-provided insurance. Another 26% are covered by Medicare or Medicaid. That leaves 14% who are uninsured in any way. Among this group, most of whom are poor and many of whom are sick, healthcare often goes a-begging, with harmful results. For example, hypertension is less controlled in this group, “sufficiently so that the annual likelihood of death in that group rose approximately 10%." (Newhouse et al, Free for All? Lessons from the RAND Health Insurance Experiment, Harvard University Press, 1993).

Twenty-two OECD countries provide more than 98% of their citizens with public health insurance covering at least hospital and in-patient care. Despite this, Americans spend less out-of-pocket than the people of most other OECD countries – 13.2%. The OECD average is nearly 20%. Studies have shown that when a people pay less out-of-pocket for healthcare, total spending rises.

3. Sophisticated medical procedures – In the movie Pat and Mike, Spencer Tracy famously said of Katherine Hepburn, "There's not much meat on her, but what there is is choice." The same can be said for hospitalizations in the US. Although hospital stays are fewer and shorter, a lot of high-powered activity goes on.

For example, the US ranks in the top five OECD countries for the rate of caesarean section childbirths as well as all forms of organ transplants with the exception of lung transplants. Moreover, we're in the top five for all four of the heart procedures on which the OECD collects data. We perform coronary bypass surgery and angioplasties at more than double the rate of the OECD average. Finally, we perform far more coronary revascularization procedures than any other OECD country. Despite performing substantially more invasive heart procedures than all other OECD countries, death rates for heart disease in the US are the 17th worst in the entire group.

4. Advertising – Between 1996 and 2003, pharmaceutical advertising quadrupled. Turn on the nightly news and count the ads for prescription drugs. Only two countries in the world allow this, the US and New Zealand. I find it amazing that more than 75% of the brands advertised had ROIs of more than 50%. Clearly, Americans respond to direct-to- consumer drug advertising, which is one reason why we spend double the OECD average on prescription drugs.

How does this all relate to workers’ compensation?
We've seen that, despite spending more on healthcare than any other country in the world, Americans don’t live longer or enjoy better health than citizens of any other OECD country. But every day, medicine practiced within workers' compensation depends entirely on the US healthcare "system," if we want to go so far as to call it that. It's certainly systemic, but perhaps systemic in a lot of the wrong ways.

Prior entries in this series:
Part Two - What does it cost?
Part One: The best Health Care Plan in America

In 1992 I became a Trustee of a major, tertiary care, teaching hospital in Massachusetts. For Trustee indoctrination, new Trustees spent a week in a classroom learning about every facet of hospital life. One morning we were briefed by the hospital's CFO. I was astonished to learn that the hospital had 27 different billing systems, one for each insurer and HMO with which it did business. To me, this was Kafkaesque. I mention it now, because in the intervening years, the situation has become worse, much worse.

At 31% of total US health care expenditures, the administrative costs of healthcare providers are double those in Canada (Woolhandler et al, New England Journal of Medicine, August 21, 2003, page 768), and, with the exception of tiny Luxembourg (population 425,000), America's health administration and insurance costs are the highest of any of the world's developed democracies.

We spend more, far more, than any other country in the world on health care. Do we get what we pay for? In Parts Two and Three of this series on health care, we examine that question. In Parts Four and Five we relate it all to workers' compensation, at 3% to 4%, a tiny room in the American health care house that Jack built.

The US compared with other developed countries: The cost explosion.

The United States has been a member of the Organization for Economic Cooperation and Development since the OECD's founding in 1961 (the forerunner of the OECD was the Organization for European Economic Cooperation, set up under the Marshall Plan in 1947). There are 30 member-countries of the OECD, all democracies, most of which are thought to be the most economically advanced nations in the world.

In September, 2007, the US Congressional Research Service, the best research group you've never heard of, published a report for Congress titled, "U.S. Health Care Spending: Comparison with Other OECD Countries." (Abstract , including downloadable full report in PDF.) This 60-page, well sourced report paints a grim, if occasionally confusing picture.

Until 1980, US spending on health care, as measured as a percentage of gross domestic product (GDP) ranked at the high end of OECD countries, but not excessively so. In 1980, US spending as a share of GDP was 8.8%, which compared favorably to Sweden's 9.0%, Denmark's 8.9%, Ireland's 8.3% and the Netherlands 7.2%. True, spending in the United Kingdom, at 5.6%, France and Norway, at 7.0%, each, and Canada, at 7.1%, was lower, but no one could claim that the US spending was out of control.

Then something happened. By 1990, our spending as a share of GDP had grown to 11.9%, while the rest of the OECD countries remained fairly static – Sweden's and Denmark's declined to 8.3%, the UK's rose to 6.0%, and so on. And by 2003, the US share had ballooned to 15.3%, nearly three percentage points higher than Switzerland, at the time our closest competitor. In fact, in 2004, the OECD average spending as a percentage share of GDP, excluding the US, was 8.6%, just over half of the US share.

In the average OECD country nearly 74% of healthcare costs are publicly financed; in the US, less than 45 %. Moreover, per capita health care spending in OECD countries, excluding the US is $2,438; in the US, per capita spending is 250% higher, at $6,102.

When analyzing why the US spends so much more on health care, one hardly knows where to begin, because in nearly every category we dwarf the field.

Take prescription drugs, for example. Average per capita spending on pharmaceuticals among all OECD countries, including the US is $383, but in the US it is $752, which is $153 dollars per person more than the second largest spender, France. Despite this, because the US spends so much on all of health care, pharmaceuticals account for only 12.3% of total spending, which is near the bottom of the pack among all OECD countries where average spending on pharmaceuticals is 17.8%.

One would think, perhaps, that spending is so much higher in the US because we have more hospitalization, or doctor visits per capita, but one would be wrong. Hospital discharges per 1,000 people in the US are 25% lower than the average for all OECD countries, and doctor visits are 42% lower.

Well, maybe people have significantly more intense and aggressive service while they are hospitalized in the US? One indicator of intensity is the average length of acute care hospital stay. In the US, the length of acute hospital stay is 5.6 days, which is less than all but eight of the other 29 OECD countries. But shorter stays could mean higher efficiency. A better way to look at it is to look at specific causes for hospital stays, like heart attacks, for instance. The US average hospital stay following acute myocardial infarction is 5.5 days, the lowest in the OECD.

Consider childbirth. Here the US has the third-lowest rate of stay, 1.9 days – much shorter than the OECD average of 3.6 days.

Another reason for high costs in the US is our aggressive testing. Only Japan has more CT scanners and MRI units per million people.

And, although doctors will roll their eyes when they read this, still another reason for our higher costs is physician compensation. At an average of $230,000 and $161,000 for specialist and general practitioner pay, respectively, each of these groups earns more than double their OECD counterparts.

Clearly then, there is no denying that, for whatever reasons, the US outspends its OECD partners by a long shot. The question that has to be asked is: Are we getting what we are paying for? All of us, taxpayers, employers, employees and individuals – the collective “we.”

That will be the subject of Part Three in this series.

Prior posts in this series:
Part 1: The best health care plan in America