Published July 08, 2009 @ 07:06AM PT
In what has been the world’s worst secret for the past two days, Vice President Biden will be announcing a deal with the American Hospital Association, Catholic Health Association and the Federation of American Hospitals.  The tradeoff:  $155 billion in cuts to hospitals in Medicare and Medicaid for a more favorable timeline for when those cuts take place than what was originally pitched by the president.  This comes on the heels of the deal with Big Pharma to close the doughnut hole, and the NY Times teases this morning that a deal with various doctors groups may be next on the horizon.  The symbolic effect of these deals is perfectly obvious.  As Rahm Emmanuel said, “The very groups we have been talking to have been the most vocal opponents of health care reform; they are now becoming the vocal proponents for health care reform.”
But symbolism aside, how impressed should we be?
The proof will be in the pudding when Biden announces the terms today, but on first glance, pretty impressed.  Big Pharma’s deal was to spend $80 billion per year to partially close the doughnut hole in Medicare Part D, but it’s unclear how this helps fund the non-Medicare push for universal health care since it’s mainly defraying costs that were paid by individuals, not the government.  In contrast, this deal with hospitals, if it’s as good as advertised, directly supports the financing of health care.
President Obama had specifically targeted some cuts to Medicare reimbursements to hospitals as part of his 2/3 savings, 1/3 new revenue mix for funding the health care reform legislation being proposed in Congress.  Like his proposal to limit charitable deductions for those making more than $250,000 a year, it’s a good idea.  But also like that proposal, Congress wasn’t falling over themselves to adopt it.  The why, was obvious – hospitals were going to hate it.  Only now they don’t.
Instead of $200 billion over 10 years, these hospitals are agreeing to $155 billion or so.  It’s also on a timeframe favorable to them.  One of the particular cuts was what’s called the “Disproportionate Share” payments – money hospitals get when they provide a disproportionate amount of uncompensated care to the uninsured.  In theory, if we get to 95%, 97% or 100% insured in this country, we should pay less for that than in our current state of 84% (or less) insured.  Of course, there were problems – although Obama’s original proposal would have phased in these cuts over a number of years, that timeline always felt artificial.  It also presumes that those now with insurance will be less expensive to treat because they’ll start receiving regular primary care, paid for at good compensation rates, rather than receiving expensive emergency care that’s uncompensated.  But it will take years for those savings to kick in.  Probably the biggest concession the hospitals got from playing ball is the recognition that these cuts will be added slowly, and only “after a significant number of people have enrolled in the new insurance programs.”  They also got a pledge that the public health insurance option won’t pay straight-up Medicare reimbursement rates – a pledge that effectively cost the Administration nothing, as none of the plans on the table for the public plan would have done that.
Think of this more as a non-aggression pact.  At the end of the day, the Obama Administration gets most of the cuts they wanted and pledge not to more aggressively pursue them.  The hospitals (who don’t represent all hospitals, but are a sizeable chunk of the industry, taken together) pledge not to fight them.  Those savings go right into paying for the expansion of health care programs without a gun-shy Congress reluctant to take on an entrenched special interest.
It’s only a fraction of the money we need, but it’s still pretty impressive.

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As the days grow shorter and summer becomes a memory, many of us will be turning our thoughts towards planning a winter vacation, especially one involving winter sports such as skiing. Travel insurance is an often overlooked part of holiday planning, but if you plan on taking part in sporting activites then it really is essential.
A normal travel insurance policy will probably not be up to the standard you need for winter sports, and if things go wrong you could be left facing a huge bill. So what features should you be looking for in a policy?
- Injury Cover
No matter how accomplished a skiier you are, hurtling down a mountain is always going to be more risky than simply lying on a beach working on a tan. And if you do have an accident, a mountainside isnt the easiest place for medical services to reach. If youre unlucky enough to need a mountain rescue or airlift to hospital, youll be facing a bill running into the thousands even before you get medical attention. This sort of expense is likely to be specifically excluded on a standard insurance policy, but will be an integral part of almost any winter sports cover.
- Equipment
Most winter sports require expensive equipment, and where there are valuables theres always the chance of theft. Your insurance should provide enough cover to fully replace your equipment with brand new items if necessary, right there at the resort. Even if you plan to hire your equipment, the hire company will probably require insurance and your own policy is likely to be cheaper than the standard one theyll try to sell you.
- Liability
Even the best skiiers or snowboarders can be involved in an accident in which someone else gets injured.

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by
IAN KLEPPER and DAVID C. KIBBE

"You never want a serious crisis to go to waste." - Rahm Emanuel, White House Chief of Staff.

Timing matters. The health industry has demonstrated steadfast resistance to reforms, but its recently diminished fortunes offer the Obama Administration an unprecedented opportunity to achieve meaningful change. The stakes are high, though. The Administration's health team must not miscalculate the industry's goals, or waver from goals that are in the nation's interest. The two are very different.

Aligning the forces of reform will be the first challenge. The White House and Congressional Democrats appear to be collaborating to develop a unified reform design. Even so, the effort is hardly pure. Lawmakers have been receptive to industry influence. The non-partisan Center for Responsive Politics reports that, in 2009, health care interests have already spent $128 million on Congressional lobbying contributions, more than any other sector. The tide now turned, most of that largess has gone to Democrats.

All reform discussions acknowledge the twin goals of universal (or expanded) coverage and controlling cost. But as the state initiatives in Massachusetts and California have shown, expanded coverage is easier. Coverage pays for care, so the industry is delighted to oblige. Cost reductions, though, are harder. The mechanisms that undergird health care's excesses are embedded in its operations, and waste is responsible for much of its profitability.

The Obama health team already has firsthand experience with the industry's maneuvering. First it saw the health IT vendors' association, HIMSS, hijack the well-intentioned $19 billion HITECH allocations for electronic health records by capturing control of the agency that specifies the certification criteria for product subsidies. Now those funds will probably favor outdated, non-interoperable, client-server technologies from a small number of legacy IT companies. Newer, more effective, less costly web-based tools from hundreds of innovative firms will likely have to base their success on market appeal, without the government's help.

And then there was the May 14 cost backpedaling by six major health industry associations. After apparently agreeing to voluntary cost reductions with President Obama, they reversed, insisting they had offered to only "ramp up savings" over an unspecified time frame. At least one health plan is already preparing an anti-reform campaign, similar to the Harry and Louise ads that helped turn public sentiment against the Clinton health reform effort.

These developments confirm the industry's focus on the status quo, backed by cash and lobbying strength. The question is whether it can again stave off reform, sealing another win at the American people's expense.

But the industry has an Achilles heel. Its fundamentals have eroded, potentially easing the way for operational restructuring. Consider the evidence that commercial health plan enrollment is in freefall, as mainstream purchasers - employers and individuals - are priced out of the coverage market.

AIS and Kaiser Family Foundation data show that, after reaching 180 million enrollees in 2005, commercial health plan enrollment has plummeted by more than 20 million lives (11.3%).

In recent discussions, health plan executives have acknowledged that the multiplier to estimate total covered lives from employee lives has fallen from 2.2 to 1.8. This 18 percent change mostly reflects kids whose parents' employers have stopped subsidizing dependent coverage. It could represent twelve million new uninsureds, previously unaccounted for, and another nine million new Medicaid lives.

Last month the Wall Street Journal cited Wellpoint's loss of 500,000 lives since December 2008, and United's loss of 900,000 in the last year. Similar enrollment declines have been reported at health plans throughout the country, the result of a decade of premium growth at four times general inflation, exacerbated by a severely downturned economy.

The Congressional Budget Office estimates that, in 2009, seven million Americans currently enrolled in commercial health plans will avail themselves of the CO
A subsidy that was part of the American Recovery and Reinvestment Act. Unless the economy rebounds or Congress extends the program, many of those enrollees will lose coverage as well.

Premium pays for nearly all health care products and services - from office visits to stents - so decreasing enrollments have stressed the industry more than at any time in memory. Ancillary issues, like drops in investment income and anticipated payment reductions to Medicare Advantage health plans, are also reverberating throughout the industry, compounding its financial troubles.

But even in the face of hemorrhaging enrollments, the health plan sector has not visibly changed its medical management approaches. Instead, most organizations seem to be waiting, presumably for the new revenues associated with universal coverage. It seems likely that the health industry will campaign for Massachusetts-type reform that forces concessions from purchasers rather than in the ways health care is financed, delivered and supplied.

To be meaningful, though, reform must fix the three deep structural flaws that enable the excesses that have benefited the health industry and created the cost crisis. A specialty- rather than primary care-dominated system promotes more expensive downstream care at the expense of less costly upstream care. The lack of an interoperable information technology infrastructure has created barriers to quality/cost transparency, transactional streamlining, and science-driven decision support. And a fee-for-service reimbursement system has encouraged more care, independent of appropriateness, rather than the right care. Industry groups fight hard to preserve these approaches and the excesses they produce, and to block the most obvious remedies to overspending.

Health care could be far more affordable. Experts agree that at least one-third of all health care cost is inappropriate care or administrative waste. As a recent White House meeting showcased, many health care managers have attained consistent, significant savings through innovations ranging from primary care clinics, data analytics, and Web-based management tools to health literacy and incentive programs.

As health care financing pressures intensify, the Administration must leverage the industry's discomfort by making the achievement of expanded coverage contingent on key operational reforms: re-empowered primary care, a national technology framework for outcomes management and payment tied to results. These are pragmatic goals that, when implemented elsewhere, have been shown to improve quality and drive down cost. Carefully explained, they will make sense to most Americans.

Finally, being effective with this immensely important issue will demand that the Obama team reach out and recruit the active leadership and support of the nation's non-health care business leaders, the one group collectively more powerful than the health care lobby.

If the Administration can get the backing of influential leaders outside health care, and if it is willing to hold out on expanded coverage until the industry accepts changes that can right-size cost, then we'll have a chance to establish affordability and sustainability in American health care.

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writing a similar brief for the SCOTUS arguing that tapes of the interrogations at Gitmo must be suppressed on the Nixonian grounds of...but youve heard all that before.
In an affidavit, CIA Director Leon E. Panetta defended the classification of records describing the contents of the 92 videotapes, their destruction by the CIA in 2005 and what he called sensitive operational information about the interrogations.
The forced disclosure of such material to the American Civil Liberties Union could be expected to result in exceptionally grave damage to the national security by informing our enemies of what we knew about them, and when, and in some instances, how we obtained the intelligence we possessed, Panetta argued.
Actually, the forced disclosure...could be expected to result in embarrassment or even war crimes charges against an ex-president, ex-vice president, ex-DefenseSec, ex-WH lawyers, and a number of other Bush Admin figures who conspired against the Constitution so they could have people thrown in jail on a whim and half-drowned just for the hell of it. A lousy reason to suppress evidence of US war crimes by top American officials.

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So, why is this an issue of reproductive justice? First, this approach recognizes that sex workers are often in the industry for reasons beyond their control, such as economic hardship or inability to enter or reenter the workforce due to lack of recognized work experience or a criminal record.  In this respect, this acknowledgement of the multiplicities of oppression reflects the values of the reproductive justice movement—harm reduction recognizes that the decision to enter or remain in the sex industry can be (but is not always) a result of economic, racial, and gender injustice.  Accordingly, rather than criminalize, patronize or demonize sex workers, harm reduction seeks to provide safer options for those who choose to continue in the sex industry.  And, because a harm reduction approach ascribes no moral judgment to the activities of others, the traditional hierarchy assumed by service provision is disrupted.  Significantly, this challenges the notion that those in positions of power “know best” while empowering sex workers to make the healthiest choice possible for themselves under their individual circumstances.  This approach also empowers sex workers to use contraceptives and educate themselves on sexual health issues.  Importantly, then, application of the harm reduction model does not demean the work that sex workers do because it both identifies the intersection of race, class, and gender-based oppression that often create the need to continue working in the sex industry and recognizes that some sex workers remain in the industry by choice.

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Allegheny Energy.  Allegheny will quickly inform you they are 95% coal.  So why do these states get a pass?
The consensus with those against this Cap and Trade scheme is it will cost the average consumer $3,100.  Now, gotta remember, thats AVERAGE.  This thing is designed to punish those in states producing coal and reward those living in states that dont.  So, you could be double that in Kentucky and Utah, and of course see no rate hike in places that use the coal like DC and Maryland.
Most economists I have looked at feel the expenses will go way beyond the initial cost to consumers.  None of tried to argue this is economically cost neutral, or even close.  What they are saying is we HAVE to do it because the world will boil if we dont.  Only problem is I havent seen much of an increase in temps since I was born.  If you go back farther, and not that much farther where I live, it was actually much hotter for a long time ( 1860s thru 1930s or so ).  Things cooled down for a while and people decided the next ice age was on the way in the 1970s and 80s.  Then Al Gore bought a bunch of stock in global warming companies and decided we all needed to use his products whether we wanted to or not, or destroy the planet if we refused.  Now, Henry Waxman has decided we dont even get the choice.  Hes going to fix the planet by cap and trade schemes.
Now, would someone please tell me how cap and trade actually reduces carbon output?  Fact is, it doesnt.  Its a tax.  By making coal energy repressively expensive, the argument is people will switch to other means of electricity like solar, wind, hydro, nuclear, or something.  We dont have tons of acreage to get any solar worth anything, wind is not an option here, they would most likely be destroyed every spring.  Try getting the environmentalists to let you build one more dam in this country.  Nuclear I like.  However, environmentalists love nothing more than to sue anyone trying to build one.  I say build them and let the environmentalists move to France.  But, it takes a long time to get a nuke going.  Until then, we have to eat.  People need to contact their legislators, especially in the Senate where California cant dominate like they do in the House.  If your state is red, you better be worried.  You better be letting your Senators know youre worried.  I truly am.
Then of course, we could burn wood and make Henry Waxman, Nancy Pelosi, and Obama happy.

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The National Council for Research on Women, with our network of 115 research, policy and advocacy centers and more than 2,000 experts, invites you to help spread awareness of what’s at stake for women, girls and the nation during these critical times. Our Big Five campaign is focusing on the real issues: economic security, health, immigration, violence, and education. We’re presenting in-depth analysis and proposing real-life solutions to ensure that the media, policy-makers and you have the information needed to engage in a fully informed and balanced debate and to develop effective policies and programs. Join us in spreading accurate information and countering myths and distortions about the lives and challenges faced by women today. We urge you to get involved, to disseminate knowledge and to work for transformative change. Together, we can make a difference, not only for women and girls, but for society as a whole, both nationally and globally.

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Note: My dad is a radi­a­tion oncol­o­gist who came out of retire­ment to take a job at the Uni­ver­sity of Mis­sis­sippi Med­ical School in Jack­son. He recently sent this letter to the pres­i­dent and has agreed to let me post it here.

Dear Pres­i­dent Obama,
I am a physi­cian who treats cancer patients at the Uni­ver­sity of Mis­sis­sippi Med­ical Center. I left pri­vate prac­tice after 30 years to do research and help the dis­ad­van­taged. In Mis­sis­sippi, I see the poor­est of the poor, and the sick­est of the sick. In my entire career prior to coming here, I have never seen as advanced cancer in so young a pop­u­la­tion as in the Mis­sis­sippi Delta black pop­u­la­tion. I was par­tic­u­larly struck by a case I saw today and want to share it with you as you look at health care reform for America.
A young (37 year old) black mother of 4 was diag­nosed as having cer­vi­cal cancer 7 months ago in her small Mis­sis­sippi Delta town. She was sent to a doctor and hos­pi­tal in a neigh­bor­ing town for a hys­terec­tomy, but was told she needed to be on Med­ic­aid or pro­duce $350 to have the treat­ment. Since she had no money, she returned home and was treated until this last week­end when she became so sick, the local hos­pi­tal admit­ted her, found the cancer had spread and blocked her kidney.

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' I have with me Dr. Margaret Flowers, co-chair of the Maryland branch of the 16,000-member Physicians for a National Health Program. She is a pediatrician, and mother of three teenagers, who left the practice of medicine about two years ago to work on health care reform full time. She spends a lot of time speaking to legislators, both local and congressional, and to the public about health care reform. Dr. Flowers explains, “I got involved because I saw how private insurers were making medical decisions that were inappropriate and because I felt like I (and others) couldn't practice quality medicine because of the tricks that insurers use to avoid paying for health care. It is wrong and people are suffering and dying because of it.” Welcome, Dr. Flowers. You must be exhausted after your ‘adventures’ on Capitol Hill Tuesday. Tell us how you and your colleagues came to be rounded up by the police. "It started last week. We, meaning some of the people who advocate for a national health system based on single payer financing, learned who the Senate Finance Committee had invited to the Roundtable on the Expansion of Health Insurance Coverage and it wasn't very reassuring. Those invited represented either a conservative viewpoint or the interests of the private insurance industry and big business. None of them represented single payer – the most efficient way to expand coverage by expanding Medicare to everyone. Several of the national groups organized call-ins to members of the committee by constituents in their states. Other groups organized having faxes sent. Despite thousands of phone calls and faxes, we learned on Monday that Sen. Baucus's office had said that there would be no more invitations to speakers for the event. The Roundtable was planned as a public event, but the public was not allowed to speak or to ask questions. In addition, it was the type of event that you must get to early and stand in line for hours just to get in. It sounded like it was going to be one more in the series of very scripted and controlled events that has characterized this "health care debate." Shortly before the meeting started, one of the people in our group, Russell Mokhiber, stood up and said something to the effect that there were no people representing single payer at the table and that there were doctors in the room who were willing to take a seat. He was arrested. Following that, we rose, one by one, and spoke out for single payer. Each of the eight of us were arrested. We were handcuffed and held for around seven hours. We were charged with Unlawful Conduct and Disruption of Congress. Our first goal was to have a seat at the table. That has been a request to Congress throughout this year, really since the presidential election. All we've asked is that when the government looks at options for health care reform that single payer is given equal attention. We would like the Congressional Budget Office to review the cost of improving and expanding Medicare to everyone. We know that this is an affordable way to provide health care to everyone. If we couldn't get a seat, at least we could expose the insincerity of the current attempt at health care reform and show that single payer was actively being excluded. And I know that we could solve these problems by creating a national health system that is based on health care as a human right. The public wants a national health system and providers want a national health system, but the Senate won't listen and actively excludes our voices.

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from Cane Island Post Acute FacilityThe philosophy of Cane Island is to improve the outcomes for our patients. The staff has followed through on that philosophy with prompt courteous response to my patients every need. Highly professional approach with attention to detail has set Cane Island above other institutions.  Dr. Sohail Noor, Chief of Staff, Christus Saint Catherines Medical Center
When I came to Cane Island, I was unable to walk and function as a person. The nursing staff, administrative staff and especially the therapy staff has allowed me to have hope and live my life again.  George Cheslick, patient
Everyone from the nursing staff, administration and therapy have been super! The care and support is the best I have ever seen.

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answered by John Halamka this week, “How do we build Health 2.0 into the delivery system?” Both Rushika and John will participate in a debate on this topic in Boston.
I am an internist who has been working for the last 5 years to design, build, and test radically new models of delivering primary care to improve experience, outcomes, and affordability of care. I currently serve as Medical Director of one of our redesigned practices in Atlantic City, NJ. Yesterday afternoon, Mr. Santos, a 53 year old Hispanic doorman at a local hotel, came in to see me quite visibly distraught. His prior primary care doctor had without asking him or discussing the issue checked a PSA (Prostate Specific Antigen) as part of his “routine” blood tests and the results were mildly positive (6.5). He was told, “Your screen for Prostate cancer was positive, you need to see a urologist right away to have it taken care of.” All he heard, of course, was “cancer” and “positive” in the same sentence. Before Mr. Santos had time to even form the first of the dozens of questions he had, the doctor had already strode out the door. Over the next few weeks, Mr. Santos went online to read about PSA and prostate cancer (which yielded over 6 million pages on Google), and started talking to his friends at work about the issue. What he surmised, quite correctly, is that the way forward for him was not at all clear, and that instead of finding answers he only had more (but better) questions. What really was his chance of having Prostate Cancer? If he did what really were the benefits of catching it so early? Were the risks of the biopsies worth this benefit? What were his other choices.

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so eloquently pointed out last week, have consistently favored health care vendors over patients and purchasers.

Health plan enrollment is now like a sieve. At a recent conference of senior health plan executives, all admitted that enrollment had recently dropped precipitously. Some members are switching to other plans. But many more are dropping out because their premiums became unaffordable, or because they've lost their jobs. The execs also agreed that the multiplier used by industry professionals to estimate the number of total lives from employee lives, stable at 2.2 for many years, has plummeted over the last few years to 1.8. If true, that would signal that increased costs have driven fewer businesses to subsidize dependent coverage, resulting in a 20% drop in total enrollment - the casualties would be mostly children here - that is NOT being reflected in the uninsurance surveys. In a related vein, HHS data from before the economic downturn show that only 39% of Florida's small businesses - they comprise 95% of all Florida businesses - still offer health coverage to their employees. This is significantly below the coverage values reported by the Kaiser Family Foundation, which makes it difficult to believe that these dynamics are accurately reflected in the surveys of those populations.
As coverage erodes, we are most concerned about the hospitals and health systems that are the anchor health care resources in most communities. With the economy and stocks tanking, the investment income that was keeping many health systems afloat has disappeared. The ranks of the uninsured and underinsured have exploded, so uncompensated care costs and bad debt are skyrocketing. Few health systems have gotten serious about huge supply chain margins, often north of 50 percent, so there's nowhere to turn in the short term. While safety net short term acute care facilities have been under duress for many years, now these trends are conspiring to also threaten the community facilities that cater to those with more resources. One recent survey of 4,500 health systems, published before the economy really began to plummet, found that more than half were "technically insolvent or at risk of insolvency."

As the economy has worsened, and jobs and money evaporate, many patients are breaking physician appointments or are unable to pay for services received. Bad debt has become much more of a problem for physician practices, so many have become more aggressive in collections. We have received anecdotal reports that some physician practices are demanding payment in full prior to procedures, and are balance-billing their health plan patients in direct violation of their contractual agreements. The health plans aren't positioned to police every practice's policies. But if this trend is widespread in the system, it suggests that the niceties of business practice are going by the wayside as practices struggle to maintain.

Finally, the combination of health coverage erosion and high care costs is fueling an arms race that, until fixes are in place, patients will lose. The two fastest growing segments of the health care financial sector are individual credit scoring and collections, specifically aimed at capturing available dollars for the system. In this economy, aggressive collections practices will drive many more patients into bankruptcy, intensifying consumer dissatisfaction and further fueling the engines of change.

Is Health Care A Bursting Bubble?
One of us recently had a 3.5 hour diagnostic procedure at a local hospital outpatient surgery center. The EOB (Explanation of Benefits) from the health plan showed the hospital had submitted a facility charge of just over $13,000 - more than four months of total income for one-third of American households - and the health plan paid approximately $1,300, which means that willing vendors and purchasers agreed that the procedure's market value was 10% of the charge.

But without insurance, we would have been legally responsible for that bill, with the willingness to negotiate utterly at the discretion of the health system. Setting aside the fact that charges are crazily tied to the evolution of Medicare cost reports and grow out of stuffing every bit of possible cost into each charge, the EOB begs three questions.
1. Is it appropriate to add a 1,000% surcharge for the sin of uninsurance. For not-for-profit health systems especially, is it appropriate to do so while receiving a tax break for providing community service?
2. When a provider chooses to pursue a receivable figure that is more than the established market value (as determined through the contractual figure with the health plan), can that effort properly be understood as inflating the market?
3. Can a system maintain stability when it inflates value beyond the means of most of its purchasers ?

The definition of a market bubble is a high variance between the intrinsic value of a product and its market valuation. Bubbles always burst eventually, as inflated market values tumble back towards intrinsic value. We're seeing this with homes and banking stocks. Are we there yet with health care services? Could America's health system collapse?

The Threat
It's hard to imagine the health care system in free fall. The federal government pays for approximately half of health care already, through allocations for Medicare, Medicaid, SCHIP, the VA, and the Federal Employees' Benefit Program. The stimulus bill allocates a "down payment" of $634 billion for health care reform over the next ten years, assuming that somehow this money will go to save health care dollars. But it could just as easily become a bail out for the failing health care sector, massively larger than the bailouts for the banks or the autos, and "too large to fail." Keep in mind that health care is now 16 percent of the US economy, one dollar in seven and one job in eleven, so large that any significant disruption in the sector would inevitably cascade to all other parts of the economy.

And the threat goes both ways. Health care could push the larger economy over the cliff, or the reduced resources associated with the downturned economy could precipitate the collapse of a health care sector that has become accustomed to inflated reimbursements. Either way, American society is vulnerable and in very big trouble.

It goes without saying that, as the funding dries up, the safety net provider organizations that deliver the lion's share of care to the medically indigent will fail first, as did Martin Luther King in Los Angeles, and as Grady in Atlanta almost did. A year ago, the safety nets' distress at the edges of the system were already the most tangible signs of the unfolding crisis. Now, the problems we've described above are with mainstream providers who cater to the middle class. What we have not seen yet is the impact on the health care supply chain, which accounts for 40 percent of health care dollars and which are also tremendously over-valued.

The Opportunity
Instability in systems that are directly connected with important societal benefit is never good, because powerless people suffer disproportionately according to caprices of fortune and the system's rules. American health care certainly fits that bill at the moment. A majority of the American people are very unhappy with the system, and nearly every sector of the health care industry is under increasing and unsustainable stress. American health care's storm clouds are gathering. It's very ugly right now, and getting worse.

The good news is that, as the system becomes becomes increasingly unstable, the opportunity also increases for a full scale overhaul of health care, as well as for the development of both policy- and market-based solutions that build on experience and that can have lasting utility. If our leaders are unwise and susceptible to special interest influence, it could also go the other way. But times like this are our best shot, because the problems are so glaring and the solutions that are in the common interest so straightforward.

Whatever path we go down, health care is certainly poised for significant change. Part of our national effort for that change must include a transition plan that consciously seeks to reduce to a minimum the turmoil involved.

Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc. David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

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I loved him in '04 — "JPL, you are the geekiest rock singer since Freddie and the Dreamers--all right?--but when you get into your geek mode--all right?--there's no one quite like you" — and I'm thrilled to see him back tonight.

7:01: Kara DioGuardi doesn't know what "provocative" means. And — wait — Tarantino isn't a guest judge. He's somehow "guiding" the contestants.

7:06: "The idea is to direct them."

7:07: Allison Iraheta is singing "I Don't Want to Miss a Thing." (The theme is music from movies.) Q thinks she's gonna do a great job. She shrieks about watching "you" sleep. The judges talk about spicy sauce (because she's Hispanic?). Simon says she's the girls' only hope, disrespecting Lil.

7:15: Anoop Desai does "Everything I Do I Do For You," and I realize I've long thought of it as the same song as "I Don't Want to Miss a Thing." Just move the words around a little and get your instant movie generic love song. Q wants Anoop to growl out the words. Q punches the air to demonstrate and, with that big jaw of his, he looks like Popeye. Anoop has a nice tone to his voice and he's modestly soulful.

7:20: Q only "got a taste" of Adam Lambert, who's doing "Born to Be Wild," and he's excited about tasting the whole thing. Adam is going to take the world in a love embrace. I just love this guy. Very thrilling and cool performance. (Hey, did I ever tell you I saw Steppenwolf in concert in 1970?) Simon tries to criticize him by saying "It was a little like watching the 'Rocky Horror' musical in parts." And Adam's all "I love that musical!"

7:29: "Have You Ever Really Loved a Woman." Incredible. I've also long thought of that as the same song as "Miss a Thing"/"Everything I Do." Is everything by Bryan Adams? Matt Giraud, the boring guy who's supposed to remind us of Justin Timberlake. Q tells him to enunciate. He's pretty bad.

7:39: Danny Gokey is doing "Endless Love" and Q's advice is to put his hands in his pockets. Which he isn't doing. Blah. I hate this. Maybe I just hate everything now that Adam is gone. Simon gives him a boost by alluding to Gokey's dead wife — the song must have been "hard" for him to sing.

7:49: Kris Allen is doing some song I've never heard of from a movie I didn't quite catch the name of. Something about a sinking boat. Q has nothing interesting to say to him. The judges are judging 2 at a time, which means we only get to hear from Simon with every other performer. I guess it would be too mean to just kick Kara off the show, but that would be a much better way to save time.

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Dear Bill Keller and Clark Hoyt – For the first time in the span of a generation, national health care reform is back on the horizon, and I’m writing to you to step back for a moment into the history of the Times’s reporting on health care reform. Last year I began a research project with two researchers from Harvard Medical School, Drs. David Himmelstein and Steffie Woolhandler, to look at the history of major state health reforms such as TennCare, the Oregon Health Plan, MinnesotaCare, and many others. A sweeping health reform bill had been passed into law in Massachusetts in 2006 that was being hailed as a unique, first-of-its-kind bipartisan strategy to achieve universal or near-universal health coverage without raising taxes or adding new regulations on the health care industry. We initially set out to find how unique the Massachusetts health reform law really was compared to previous state efforts, and to see if by analyzing the outcomes of those earlier reform efforts we could learn some lessons about what to expect in Massachusetts.

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The question is can you do this faster and more effectively than your competitors?
The winner of any business competition is determined by THE CUSTOMER
In any competitive situation, its a race to see which of the competitors can effectively re-orient themselves to the rapidly changing customer priorities and, in doing so, outmaneuver their competitors. An organization that can OBSERVE - ORIENT - DECIDE - ACT faster and more effectively than their competitors will be able to remain relevant, retain and grow their business, and build the strongest customer relationships.
There are many great examples of this. One classic is the Honda - Yamaha Honda learned that Yamaha was planning to build a large factory to ramp up production of motorcycles. However, rather than responding to this competitive threat by building another factory of their own, they out maneuvered Yamaha by concentrating on business processes that allowed them to quickly release a flood of new models aimed at the rapidly changing concept of what customers would find compelling. Customers responded positively and Honda emerged with the advantage and additional market share.
There are numerous other outstanding examples, including the way weve seen Dell outmaneuver many of the other PC manufacturers in the late Weve seen WalMart outmaneuver just about every other mass market retailer over the past 20 years. Weve also seen Toyota outmaneuver GM and Ford, Southwest outmaneuver Delta and American, Best Buy outmaneuver Circuit City, and were currently seeing Google and Apple outmaneuver Microsoft today. In each of these cases, the prevailing organization has done a better job of OBSERVE - ORIENT - DECIDE - ACT and the winner has been determined by the customer.
Weve applied the core principles of agile maneuver in our work with clients over the last decade.

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Listen to anyone caring for an elderly, frail, or chronically ill family member, and you'll hear a litany of worries. They'll tell you about medical specialists who don't coordinate with one another. Patients who are sent home from the hospital or rehab without adequate information about follow up care and complex medication regimes. Delays in getting patients the care they need when they need it. In short, a fragmented, disconnected system that seems unaware that it's supposed to be all about the patient.
You're on your own, said Carol Levine, director of the families and health care project at the United Hospital Fund, who cared for her own husband for 17 years after a car accident made him a quadriplegic. The system has gotten worse. It's more complex. There are more transitions.
What can health care reform do to address these problems.

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post concerning reigning in medical care costs. In it he notes that a substantial share of our national spending on health care contributes little if anything to overall health.  He calls for providing incentives to control costs and sharing of information concerning the effectiveness of treatment. Then he makes an interesting comment: the current unlimited tax exclusion for employment-based health insurance dampens incentives for costs control. Those incentives could be changed by restructuring the tax exclusion in ways that would encourage workers to join health plans with higher cost-sharing requirements and tighter management of benefits.
This opens up a host of interesting worm-filled cans. During the presidential campaign, Republican Senator John McCain called for taxing the value of health care coverage (along with offsetting tax credits). The Democratic nominee, now President Barack Obama castigated the idea, calling it the biggest tax increase on the middle class in history. However, many in Congress of both parties are reviving the idea. OMB Director Orzag has indicated that all ideas, even taxing the value of health care coverage, needs to be on the table. Few other comments on the topic have been forthcoming from the Administration, but realistically, paying for the cost of universal coverage will require at least a strong look at this revenue option.
On the surface, this makes a lot of sense. The current system is regressive, meaning it is a better deal for the wealthy than for lower income Americans. The higher your tax bracket and the richer your benefits, the better the current system works for you. For example, a CEO earning $500,000 a year, paying an effective tax rate of 40 percent (state and local) and receiving health insurance benefits worth $10,000 per year. If the coverage was taxed, our hypothetical CEO would pay $4,000 in taxes. Instead, she gets a from the tax code of this amount. Working for this CEO is a clerk, earning $40,000 per year and paying 15 percent in taxes with the same coverage. If the value of health insurance was taxed the employee would pay $1,500 in taxes his gift is less than half of the CEOs.
You might think Democrats would be jumping all over this loophole. After all, theyre the party of progressive taxes. Instead, those few who are willing to raise the issue are demonstrating real political courage. Because unions, who contributed millions of dollars and armies of foot soldiers into the election of a Democratic Congress and President, are adamantly opposed to taxing benefits.
For decades, unions have negotiated rich health care benefits for their members in lieu of salary increases. Their members valued the coverage, which was received tax free. It was a reasonable trade-off for employers they can deduct the cost of health insurance just as easily as they deduct the cost of salaries. Changing the rules of the game would, in essence, punish union members for doing what economists say everyone should do: pursue economic self-interest based on the rules of the game.
There are ways to mitigate the pain unions will feel if health insurance is taxed. As Mr. Elmendorf notes, the tax rules can be modified rather than eliminated so as to encourage consumers to choose cost effective plans. Or the value of union negotiated health benefits could be exempted from the tax for a transitional period, allowing unions and employers to negotiate new contracts under the new rules.
Health care reform is going to be expensive covering all Americans will cost over $1 trillion. Were already spending large sums to salvage the tattered economy (and, apparently, to enrich the AIG traders who helped get us into this mess). Yes, the government can print the dollars it needs, but that leads to another problem which goes by the name of  inflation.
If health care reform is going to be enacted in the next 12-to-18 months, which I think it will, the money for reform will need to be identified. My guess is taxing health care coverage will be one of those sources. It wont be a straight repeal of the current exemption, it may be offset with subsidies and credits, some coverage may be grandfathered for awhile, but the tax is coming. 
Meaningful health care reform will change a lot of the rules were used to. This is just one of them.

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By MARGALIT GUR-ARIE
As part of a sweeping effort to address the woes of the current US economy, the government has placed $19 billion on the table for HIT, aimed at containing healthcare costs and creating new jobs. The ultimate instruments for implementing this HITECH bill are America’s physicians and there is much confusion and apprehension in the physician community regarding the net effects of this bill on doctors in particular and healthcare in general. The HIT stimulus effort will not reach its stated objectives without voluntary adoption by our doctors. The government and the HIT community must find a way to draw physicians all over this country into the process of defining and implementing the stimulus package.
In very broad terms, interoperability standards will be defined, Electronic Health Records (EHR) technologies will certify compliance with the standards and physicians will be provided financial incentives to acquire, and meaningfully use, those EHR technologies. The assumptions are that use of these standardized EHRs will reduce costs by reducing medical errors, reducing duplication of tests, improving quality of care and encouraging evidence based clinical decisions. Jobs will be created as the EHRs are deployed across the nation. Experts are already at work “on the Hill”, in the White House, in the boardrooms of HITSP, NIST, CCHIT and other acronym organizations. Technology vendors are feverishly doing their part, from creating websites devoted to the HITECH bill, to making products available at Wal-Mart, to sudden revelations that HIT is really their main business. Everybody is actively involved in making this bill a success. Well, maybe not everybody.
Continue reading "For whom the HITECH Bill Tolls.

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http://cli.gs/1U5yEZ

Dick Durbin has a nasty surprise for two of Sasha and Malia Obama's new schoolmates. And it puts the president in an awkward position.

The children are Sarah and James Parker. Like the Obama girls, Sarah and James attend the Sidwell Friends School in our nation's capital. Unlike the Obama girls, they could not afford the school without the $7,500 voucher they receive from the D.C. Opportunity Scholarship program. Unfortunately, a spending bill the Senate takes up this week includes a poison pill that would kill this program -- and with it perhaps the Parker children's hopes for a Sidwell diploma.
[Main Street] Deborah Parker

Sarah and James Parker attend Sidwell Friends School with the president's daughters, thanks to a voucher program Sen. Dick Durbin wants to end.

Known as the "Durbin language" after the Illinois Democrat who came up with it last year, the provision mandates that the scholarship program ends after the next school year unless Congress reauthorizes it and the District of Columbia approves. The beauty of this language is that it allows opponents to kill the program simply by doing nothing. Just the sort of sneaky maneuver that's so handy when you don't want inner-city moms and dads to catch on that you are cutting one of their lifelines.

Deborah Parker says such a move would be devastating for her kids. "I once took Sarah to Roosevelt High School to see its metal detectors and security guards," she says. "I wanted to scare her into appreciation for what she has at Sidwell." It's not just safety, either. According to the latest test scores, fewer than half of Roosevelt's students are proficient in reading or math.

That's the reality that the Parkers and 1,700 other low-income students face if Sen. Durbin and his allies get their way. And it points to perhaps the most odious of double standards in American life today: the way some of our loudest champions of public education vote to keep other people's children -- mostly inner-city blacks and Latinos -- trapped in schools where they'd never let their own kids set foot.

This double standard is largely unchallenged by either the teachers' unions or the press corps. For the teachers' unions, it's a fairly cold-blooded calculation. They're willing to look the other way at lawmakers who chose private or parochial schools for their own kids -- so long as these lawmakers vote in ways that keep the union grip on the public schools intact and an escape hatch like vouchers bolted.

As for the press, complaints tend to be limited to the odd column or editorial. That's one reason it was so startling back in 2000 when Time magazine's Tamala Edwards, during a live televised debate at Harlem's Apollo Theater, asked Al Gore about the propriety of sending his own son to private school while opposing any effort to extend the same choice to African-Americans without his financial wherewithal. As CNN's Jeff Greenfield would note later in the same debate, Mr. Gore "bristled" when Ms. Edward's put the question to him.

Virginia Walden-Ford, executive director of D.C. Parents for School Choice, wouldn't mind making a few more politicians bristle. "I'd like to see a reporter stand up at one of those nationally televised press conferences and ask President Obama what he thinks about what his own party is doing to keep two innocent kids from attending the same school where he sends his?"

As for Sidwell, the school has welcomed the Opportunity Scholarship program. Though headmaster Bruce Stewart declines to get into either politics or the Obamas, he says that a program that gives parents more educational options for their children is not only good for their kids, it's good for the community. Plainly he's not doing it for the money: Even the full D.C. voucher covers only a small fraction of Sidwell's actual costs.

All of which leaves the First Parent with a decision to make: Will he stand up for those like his own children's schoolmates -- or stand in front of the Sidwell door with Mr. Durbin? It's hard to imagine white congressional Democrats going up against him if he called them out on an issue where they have put him in this embarrassing position. This, after all, is a man who has written of the "anger" he felt as a community organizer, when his attempts to improve things for Chicago school kids ran up against an "uncomfortable fact."

"The biggest source of resistance [to reform]," he said, "was rarely talked about . . . namely, the uncomfortable fact that every one of our churches was filled with teachers, principals, and district superintendents. Few of these educators sent their own children to public schools; they knew too much for that. But they would defend the status quo with the same skill and vigor as their white counterparts of two decades before."

Let's just say that Sarah and James Parker -- and thousands just like them -- could use some of that same Obama anger right about now.

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