Recently in Health care Category

According to Medscape's newly published (2012) report on physician income, almost half (46%) of the surveyed physicians (N > 25,000) would not choose medicine as a career, and nearly 80% would not choose the same practice setting, if they had to do it over again. Nearly 60% regret their specialty choice. Perhaps income, especially for radiologists and orthopedic surgeons, lightens the emotional load. But money can soothe only so much unhappiness.

The distressing thought for the day: The general dissatisfaction among currently practicing physicians bodes ill for encouraging bright young adults to pursue medical careers.

Law professor Mark Hall (Wake Forest) makes predictions in the latest NEJM about the Supreme Court's decision on the recently argued Affordable Care Act (ACA)—specifically with respect to the constitutionality of the individual insurance mandate. (Although frankly, anyone who's been watching this story could make the same predictions.)

• The 4 Democratic appointees (Ginsberg, Breyer, Sotomayor, Kagan) will vote to uphold the ACA (and thereby the individual mandate).
• Consequently only 1 Republican appointee is needed to side with the Democratic appointees to uphold the ACA. However, there is "no clear support" from the 5 Republican appointees (Roberts, Scalia, Kennedy, Thomas, Alito). Nevertheless, Kennedy is historically a critical swing vote in close decisions, and his statements during the recent argument indicate that he is able to consider both sides of the issues.
  
• It is "very unclear" if the Supremes will toss the ACA, if the individual mandate is declared unconstitutional.
• While some justices appear to be against the Medicaid expansion (which was originally thought to be a non-starter), it is unlikely that there will be enough votes to 86 the provision.

A decision is expected by the end of June.

Today: Premature or ripe?
Tomorrow: Insurance mandate constitutional or unconstitutional?

This week's NEJM offers a very nice we-are-here review of the status of PPACA (aka ObamaCare) and the Supremes' anticipated review of the appellate case, Florida v HHS (which challenges the constitutionality of the law), on March 26th-28th. The 4 questions that the ultimate court will address in the ultimate appeal of this case, according to authors Curfman et al, are the following:

1. Whether contesting the law is premature. In other words, can the legality of a tax (or penalty or whatever) for not buying health insurance be challenged before the tax is levied (in the case of PPACA, in 2014)?
2. If the Supremes decide that a legal review is not premature (ripe?), does Congress have the authority to mandate the purchase of health insurance or levy a tax (or penalty or whatever) for not doing so? Evidently much of this decision rests on the interpretation of the Commerce Clause. A related concern is whether Congress can tax (penalize, whatever) US citizens for not buying a product from a private entity (eg, health insurance or, by extension according to one lower-court judge, a car or broccoli).
3. If the mandate is unconstitutional, the Supremes must then decide if the mandate can be excised from the law or if the entirety of PPACA must be tossed.
4. Last the Supremes must determine if PPACA's expansion of Medicaid exceeds the authority of the federal government to regulate states' voluntary operation of Medicaid programs. Curfman et al note that lower courts have considered this argument a non-starter, but the high court said it would consider it anyway.

Also the NEJM provides yet-another neato, interactive graphic of the case decisions to date.

• 7 at the district court level (1 dismissed, 3 in which PPACA was upheld, 3 in which PPACA was unconstitutional).
• 6 at the appellate court level (4 dismissed, 2 in which PPACA was upheld, 1 in which in which PPACA was unconstitutional)

The one appellate case in which PPACA was determined to be unconstitutional, Florida v HHS, is the case that will be considered by the Supremes later this month.

PPACA = Patient Protection and Affordable Care Act.

In a Pharmalot interview, money manager, blogger, and diabetic David Kliff absolutely excoriates "Buttah Queen" Paula Deen and insulin-maker Novo Nordisk for their newly announced, and arguably duplicitous, promotional relationship. Kliff easily tosses out words like "hypocrite," "shyster," and "bastardizing" like so many fat calories in a bacon-and-fried-egg hamburger with doughnut buns.

The intriguing "Do Nothing" option for reducing the country's $15-trillion deficit ostensibly includes a passive stance toward a looming cut to physicians' Medicare reimbursement on January 1. The ever-escalating SGR-defined cut, which has been stayed numerous times by Congress over the years, now exceeds a practice-killing 27%. Primary care physician Don Klitgaard in Iowa, interviewed by the Associated Press, predicts along with the rest of us that "there's going to be a temporary fix, because the health care system is going to implode without it." But an unidentified "senior Washington lobbyist" warns, "It's entirely possible given past performance that Congress misses the deadline." Compromise solutions are reportedly being entertained; they are painful, but not necessarily draconian, for physicians.

SGR = sustainable growth rate.

Image of Westall's Sword of Damocles (1812) from Wikipedia. Meh: not a perfect analogy but close enough.

I have to say that the most astonishing finding from President Obama's most recent routine physical examination is not that he's smoke-free or that his LDL fell with presumptive dietary changes or that he even got a PSA test but that he has 20/20 vision, near and far, without correction. Who the hell doesn't have to wear glasses for something after the age of 50?

Photo of a glassless #44, from http://www.whitehouse.gov/about/presidents/barackobama.

This week's NEJM provides a useful barometer article, including a neato graphic timeline, on the litigation status of [PP]ACA ("Not So Fast—Jusisdictional Barriers to the ACA Litigation"). Thanks, Mssrs Jost and Hall.

Their salient points:

• So far, ~30 lawsuits have been filed against the ACA.
• A Supremes' decision in June 2012 is likely, given the admin's petition for their review on September 28.
• The jurisdictional issues generally, which are somewhat intertwined, rest on one of the following:
• Whether Congress exceeded its constitutional authority when imposing the individual mandate to purchase insurance.
• Whether state or individual plaintiffs have standing when challenging the ACA—particularly, in the latter case, before the "meat" of the ACA (eg, the individual mandate) goes into effect in 2014.
• Whether grievances are sufficiently ripe—meaning whether cases have been filed prematurely (before the "meat" of the ACA goes into effect in 2014).
• Whether the fine for not purchasing insurance is a penalty or tax or something else altogether (eg, an "exaction"*) and whether the label really makes any difference (the answer: it seems to; in fact, maybe big time).

My favorite part of the article, however, is the reference for the table outlining the status of 6 ACA cases.** It is the ACA Litigation Blog (a blog!), evidently run by Santa Clara law professor Brad Joondeph. Har-dee-har-har, NEJM.

ACA = Affordable Care Act.

* Haven't heard that one yet.
** For scorekeepers: 1, it's constitutional; 1, it's unconstitutional; 4, no jurisdiction; 1, decision pending.

There are few press releases crowding my inbox that merit attention, but today's e-mail from the National Union of Healthcare Workers (NUHW), if true, is a stunner.

According to a new report from the union, the average annual combined pay and benefits* for CEOs at California's largest HMOs is $7.4 million. Million. Million.

And this obscene compensation is in the context of, as if anybody didn't already know, historic economic hardship and escalating healthcare costs. The most well-compensated execs were Wellpoint's Angela Braly ($13.1 million) and Kaiser Pemanente's George Halvorson ($7.9 million as of 2009), the CEO of the tax-exempt and ostensibly nonprofit HMO. (They earn every penny.) The president and COO of Kaiser, Bernard Tyson, according to NUHW, receives 8 separate pension and retirement plans.

Contrast these compensation packages, the NUHW says, with the average weekly income of the American worker in late 2010: $752 (or about $39,000 yearly). And after adjusting for inflation, the NUHW argues, workers are actually making less, because in part (hey, get this) a large part of inflation is due to rising healthcare costs. Before adjusting for inflation, the annual raise for the average American worker was a paltry 0.5%, says the NUHW, whereas some Kaiser execs received payment increases just last week of more than 17%.

The NUHW scolds, nay excoriates, Kaiser for "awarding its executives a king's ransom" while "raising member rates and demanding huge economic concessions from their employees who provide the health care." The apparent instigator of this executive-damning report is management's attempt to "eliminate employees' only defined-benefit pension plan."

And although the NUHW report focuses on Kaiser, the overpayment of healthcare execs isn't limited to the company (to noone's real surprise). Samuel Downing, former CEO of the Salinas Valley Memorial Healthcare District, got a cash severance of $947,594 in 2008, $3.9 million in one-time retirement payments this year, and generous ongoing payments from a regular pension plan. His base annual salary, while serving a 226-bed public hospital in Salinas, was $670,000. In an attempt to find revenue for Dowling's payout, the hospital tried to lay off 200 frontline healthcare workers, the NUHW claims. The union says that regular annual pay increases (from ~6% to ~30%) were provided to other Salinas execs between 2005 and 2010.

* Including perks like bonuses, multiple pensions, homes (homes!?), personal drivers, paid travel, access to corporate jets, and so-call gross-ups--in which execs are able to write off associated taxes on benefits.

Photo of Angela Braly from Wellpoint website.

Congressional leaders agree that the SGR formula, the legislated formula used to calculate ongoing cuts in Medicare reimbursement to physicians, has to go. But passing a permanent fix has been stymied, in part, by the nature of the legislative calendar, said Congressman Michael Burgess, MD (R-TX) yesterday to MedPage Today. Congress has consistently had trouble getting its act together to pass a reform bill before the August recess, Burgess implied to the medical news source.

Several medical societies, including the AMA, recently submitted their SGR alternatives to the House Energy and Commerce Committee, which requested the proposals in late March, reported Medscape's Robert Lowes 3 days ago. The committee, which held a public hearing on the topic yesterday, is in charge of spearheading some type of Medicare-reimbursement reform measure.

The current stop-gap measure to suspend the SGR formula, enacted in December, delays the legislated cut until January 1 of next year, at which time Medicare reimbursement will drop by a practice-shocking 30%.

SGR = sustainable growth rate.

Photo of weathered can from magannie at Flickr.