Commentary from Dave Durenberger

October 31, 2007

TRICKS
In Minnesota we started tricks and treating early in the week. Governor Tim Pawlenty returned from a week's trade mission in India to announce that Indian corporate giant Essar Global is going to acquire and invest in a $1.6 billion makeover of the Minnesota Steel Industries plant in Nashwauk on our declining iron range in northeast MN. Until he received a call from his Republican friends in Washington informing him that Essar Global of Mumbai may be doing energy business with Iran.

So our Governor is preparing to throw his new Indian friends (and his new iron range friends) overboard for his President's so far unsuccessful Middle East policy. Pawlenty's spokesman says:" Even if the company decided to make the infrastructure improvements [in MN] on its own, that doesn't mean we would support having this company do business in Minnesota...We would oppose the permits or take other action." What might happen if Dick Cheney's Halliburton was looking for permits to build in Minnesota? Yeah?

TREATS
Our Governor surprised everyone this week by announcing that Arctic and Antarctic explorer Will Steger has convinced him of the threat to our state from drastic climate changes. Pawlenty has even hinted at rendezvousing with Steger during Steger's planned trip to the Canadian Arctic this coming spring. Steger led the first expedition on foot and dogsled in 75 years to the North Pole and was the first to traverse the nearly 5,000 miles of Antarctica. After returning from the last trip (in 1990), I introduced him to Tennessee Senator Al Gore. During a ceremony for the expedition on the White House lawn with President Bush 41, and at his request, I introduced Will to Barbara Bush. Gore ended up spending over an hour with Steger and Mrs. Bush was polite.

©2007 Don Wright, Palm Beach Post

TRICKS...OTHER MINNESOTA PRIORITIES
Various committees and commissions have been examining how to improve the performance of MN's health care system during the last five years. At least four involving legislators and health leaders are currently at work. Little or no public funding had been invested in any of these efforts despite the multi-billion dollar impact on Minnesotans of just the increase in healthcare costs the last five years. But earlier this week the Minnesota Senate Rules and Administration Committee approved spending $500,000 to hire an investigator and staff to look at the MN Department of Transportation management practices.

MINNESOTA LEADERSHIP
The National Institutes of Mental Health recently recognized the tremendous potential for good in an Institute for Clinical Systems Improvement (ICSI) proposal to improve the interface between mental and physical ailments. NIMH provided a $3 million grant to HealthPartners Research Foundation to study whether a case management demo that brings psych professionals to primary care clinics. All of Minnesota's largest nonprofit health plans are taking part and ICSI expects the plan to save at least $1,000 per patient. The project's acronym is DIAMOND. Watch it.

LOUISIANA LEADERSHIP
Watch newly-elected Governor Bobby Jindal at work in Louisiana for the next four years. While he happens to be the first Indian elected a Governor in the U.S., he won't be the last. The standard he sets for those who follow - and for Governors everywhere - will be hard to match. There is not a challenge this 36 year old has not met and mastered in his public service career. He'll make a lot of people forget Katrina. Except for "Brownie". Speaking of whom, Brownie must have left a cousin at FEMA when he was canned. The guy who staged a FEMA Press conference to grandstand the agency's performance in the southern California fires, using FEMA employees as pretend reporters, also took an early out. Believe it or not, he is going to be the chief spokesperson for the Bush administrations national intelligence services. Must have passed a competitive exam to get it.

TRICKS...THE MN MEDICAL ARMS RACE continues as Children's Hospitals and Clinics of Minnesota wages advertising wars with University of Minnesota Children's Hospital, Fairview. As reported here many times, they are battling for the loyalties of moms and kids and pediatric specialty professions and plan to use nearly a half billion of our dollars, much of it public subsidies, on new facilities and equipment in their competing efforts.

OVERTREATED
Shannon Brownlee's book has attracted a much larger audience than I ever anticipated. We will easily have over 200 people at St. Thomas November 15th to hear the author present on "Why too much medicine is making us sicker and poorer." This is really the story of Dr. Jack Wennberg and his colleagues in the evaluative sciences business at Dartmouth University. It is the story of where to look for American solutions if we can't afford to go to Holland or Switzerland. Brownlee will autograph books after a 5:30 pm to 7:00 pm colloquy. Refreshments are available both before and after.

TREATS
On November 1st - tomorrow - Jack Wennberg will be honored at the 25th Anniversary meeting of Academy Health in Washington, DC. He is being honored, finally, because, more than anyone else, he has been able to translate research and practice into the reality of American medicine. To date, decades of his research and his conclusions have been of interest to professionals like him and reformers like me. But the American public, who need to use this reality to force change in the practice of medicine and the financing of health and medicine, have been totally unaware of the Dartmouth Atlas and the people involved. Hopefully, Brownlee's "Overtreated" will serve to wake us all up.

TRICKS...SOCIALIZED MEDICINE
HHS Secretary Mike Leavitt is off to Switzerland and the Netherlands to check out the next "Big Thing" in health system reform. For some strange reason, academic researchers and healthcare associations are trotting out Dutch and Swiss experts to help solve America's decades old health care cost control problems. Scary. And the editors of the Wall Street Journal found a Manhattan Institute researcher who discovered that the cost of "Medicare for All" would cost more than twice as much as privatized Medicare Advantage. They say the current Medicare program, which we already know costs 15% less than Medicare Advantage, has administrative costs which include the costs of tax collection, underwriting, utilization inducements. Yes. And the biggest seller of MA in the country has a medical loss ratio of 79% - meaning 21% admin costs against traditional Medicare's 3%.

TREATS...HEALTH PLAN QUALITY
This week you can buy U.S. News and World Report if you care about the quality of your health insurance plan. Or about the one you may have an option to buy during "open season" in November. So how many of us care about the quality, as opposed to the price and reliability, of our health insurance plans? Not many I'd guess. So why does the National Committee on Quality Assurance (NCQA), on whose Board I serve, provide the means for ranking the nation's health insurance plans? Because we provide the leadership necessary in this country to improve the quality of health and medical services financed through health insurance. So we're not selling health insurance plan quality as much as healthcare service quality. Get it?

Most people don't. Peter Farrow runs 65,000-member Group Health of Eau Claire (WI). He buys HEDIS quality measurement and CAPHS measurement services from NCQA, but his Board won't pay the nearly $300,000 for accreditation by NCQA because, in its part of the western Wisconsin world, there's as yet little evidence that the 65,000 members of Group Health buy among three or four plan choices on the basis of accreditation. On the other hand, Group Health has always been one of the highest-rated non-accredited plans in the nation with the lowest complaint rates anywhere. Has he ever had a call from a customer who has asked why they weren't ranked in US News? "Only from the guy I succeeded as CEO", says Peter. Group Health of South Central, WI ranks among the U.S. "top 10". Their actual health service access ratings are comparable to GHEC, but they pay for accreditation because the large employer market in Madison, WI has made NCQA accreditation a competitive distinction worth owning.

What's really going on here is an effort to engage the most knowledgeable buyers of healthcare services in a nationwide effort to change and improve the quality of care delivery, consumer satisfaction, and healthcare financing so when we the consumers are really ready to make value-based choices we will have the assurance of comparable choices. There is no question about wide variance in health quality within hospital systems, medical groups, between communities and across specialties. What to do about it? We consumers aren't going to change this picture one decision at a time. So we turn to our health insurance plans and to groups of larger employers who have a financial stake in improving price, value, and satisfaction of our buy decisions.

©2007 Mike Luckovich, Atlantic Journal Constitution

Even though national rankings of health insurance plans don't prove to me that no. l in Boston (ranked no.1 in America) is that much better than no. 1 in Minnesota (ranked 38th in America) I know how hard no. 38 is working to improve especially its consumer satisfaction scores because they want to be no. 1 in America. MN plans may compete differently from Boston plans. Boston consumers may like their health plans better than Minnesotans like theirs. Lake Wobegoners may just be reluctant to say anything superlative about anyone.

That's not the point. Whether you are a MN plan that ranks No. 8 nationally in CMS Performance Assessment for its Senior Plans, or a MN plan that ranks close to the top nationally on EVALUATE - which is the large employer quality/satisfaction scoring that comes out soon, makes no difference. You are working hard, and spending a lot of money not just on rating services, but investing in quality improvement with physicians groups and customer satisfaction of your members. Isn't that the goal we all seek?

The national task of assessing what is health care quality and what is not is enormous. The task of assessing for consumers the role that health plans should play is so big policy-makers choose not to take it on. NCQA has been the national leader in developing measures of performance quality and quality assurance. Today lots of folks are playing in the sandbox NCQA helped create and the healthcare consumer is not yet receiving what we really need. As my little survey reveals, some plans buy HEDIS from NCQA or utilization review from URAC or CAPHS or EVALUATE from large employer groups the latest P4P or episodic grouper or anything to help measure and distinguish and encourage and discourage. What's important is we are all working hard to define value in everything consumers buy in healthcare.

TRICKS...HOSPITAL SCARY
I used to tell audiences that one of the problems in our health system is the large number of "This is Not a Bill" statements we all receive. That's not the scary problem. Medical Billing Advocates of America is a new for-profit business created by the ineptitude of America's medical billing systems. It claims that 8 out of 10 hospital bills they examine contain billing errors, including medical coding, billing for unperformed services, failure to provide discounts, and fraud.

Just like the answer to hospital safety is for patients to go armed with questions, the advice from Watson Wyatt consulting is that we need to do a better job checking the statements we receive. As I was reading this, my wife showed me a package of glaucoma prescription drugs she received in the mail, with the name of a prescribing physician she found listed in Las Vegas. I advised her to flush them down the toilet. She insisted on calling the mail order house and they said mail it back and send us the bill. Come off it!

NEXT MEDICAL ETHICS SHOE TO FALL
The U.S. Attorney's office in Newark N.J. cut a deal with four large orthopedic device manufacturers in September to forego their civil liability for conspiracy to violate anti-kickback statues. The companies paid $310 million in penalties. Next big disclosure from the DA's office will be the names of America's orthopedic surgeons who "made medical decisions on how much money they could make - choosing which device to implant by going to the highest bidder."

TREATS AND TRICKS
The Veterans Administration finally gets a new Secretary in Viet Nam vet and former Army Surgeon General Dr. James B. Peake. Sounds like a good move. The bad news is that 1.8 million U.S. veterans remain without dependable access to affordable health insurance. A new President will have the courage to recommend to Congress what Phillip Longman recommended to all of us in his recent book on the VA Health System, Best Care Anywhere. That all veterans be entitled to use of the VA health system as a choice between their local system and the VA. Phil also suggests a way to accomplish that without the extra costs of expanding the infrastructure of the VA.

TRICKS...PRESCRIPTION DRUG COVERAGE
Private insurance giants United Health Group and Humana have priced 1.6 million seniors out of their current prescription drug plans. In some of the largest states in the country these top two Medicare sellers have submitted bids for 2008 which will require beneficiaries to go find other plans. Perhaps United is covering for the $2 billion it has to pay back to CMS for missing the "bid corridors" in MA plans. CMS says they will help. But in traditional Medicare you wouldn't have this problem. It is not taking us long to find that private insurance competition is not necessarily the best nor the cheapest way for Medicare beneficiaries to access prescription drugs.

TRICKS...SELLING FINANCIAL SECURITY TO OLDER AMERICANS
October's AARP Bulletin alerts me "Don't Fall for the Hard Sell." AARP is alerting its members to the downsides of private Medicare rather than Traditional Medicare (or "socialized medicine" as their GOP friends call it.) AARP's problem is with the hundreds of thousands of insurance agents who peddle these new plans and their prescription drug cousins to elderly folks used to dealing with Medicare as they and their parents knew it. These agents get paid a lot more for selling MA plans than drug or medigap plans, something like $250 to $500 per sale. Most complaints are addressed at the only part of MA that is growing - private fee for service - in which provider availability especially is being misrepresented. Starting in January, AARP will be selling its United Health/AARP MA plan. We'll find out then what kind of "trustworthy" agents we will be dealing with.

German insurance company Allianz has US headquarters in MSP and has been under fire for sales practices in the insurance and annuities area for several years. Minnesota's Republican Department of Commerce has been slow to take action against Allianz and has done so recently in part because MN's Democratic attorney general has targeted the company. The Allianz deputy general counsel is a former Commerce Dept employee. As part of a recent settlement Allianz hired another Commerce Department Assistant Commissioner as its "Assurance Officer" presumably to make us purchasers feel protected.

Another Minnesota financial giant - Ameriprise - is in some trouble with the elderly. According to the Wall Street Journal state regulators are after the company for pitching financial analysis/planning products to older Americans, not delivering the promised product and then forging customers names to make it appear as though they had. The Consumer Federation of America claims that over time the term "financial plan" has been so watered down by these companies that it means almost anything from the complex advice most of us think we need, to a phone call. Apparently this is not the first incident. American Express Financial Advisors has already settled a fraud suit for $100 million without admitting wrongdoing.

©2007 Mike Luckovich, Atlantic Journal Constitution

CATHOLIC SCARY
U.S. Roman Catholic Bishops meet in Baltimore next week to prepare the church's advice to its members on how to vote in the 2008 Presidential election campaign. Of concern to many is the growing strength of more conservative church leaders to make issues like abortion, euthanasia, embryonic-stem-cell research, human cloning, and same-sex marriage "non-negotiable" which, I guess, means you're out of the church if you disagree. Everyone remembers the "wafer watch" around 2004 Democratic and Catholic candidate John Kerry who was told not to receive the sacraments in certain dioceses. From headquarters in Rome comes word from Pope Benedict that the Church strongly endorses health professionals allowing their Catholic consciences to deny services which may be determined to be "medically necessary" by a physician or surgeon to a patient who requests them.

THE AXIS OF EVIL...PART THREE
After deciding to make war on Iraq in response to the September 2001attacks on us, President Bush has been able to smoke out North Korea and Pakistan's role in peddling nuclear technology. He is using some diplomacy to bring North Korea's Kim Jong Il nearer to a resolution of the quandary created by his cultist father Kim Il Sung. The Persians in Iran and the religious cultists who have spoken for the people of that nation for 30 years are another problem. President Bush and Republican candidates for President intend to deal differently with Iran. And that scares the hell out of me. Watching Giuliani's spokesman, and one of Bush's neocons, Norman Podhoretz (also a Commentary publisher), on The Newshour with Jim Lehrer did me in.

©2007 Steve Sack, Minneapolis Star Tribune

Podhoretz calls opponents of administration efforts to take out the military and nuclear capacity of the Iranian mullahs by whatever means "Irresponsible complacency remindful of the Nazis and Hitler." Speaking for the rest of us "appeasers", Fareed Zakaria of Newsweek demonstrated from the time of Joseph Stalin and the secrets stolen from post-WW II Americans and China's Mao Tse Tung's pledges to make USA disappear, the nuclear bomb-owners have been deterred from using their power to fulfill threats which are more for internal consumption than for Armageddon. "The desire for self-preservation is always stronger than the desire for superiority at all costs." Israel has more than 200 nukes of varying sizes. Saddam Hussein thought he needed just one. The current Iran helped the U.S. in its efforts to de-Talibanize Afghanistan, despite our history of feeding Iraq's eight-year war on Iran. Self-preservation....I thought when Bush started beating up on Fidel Castro and Cuba a couple weeks ago we'd heard the last of his wars. Let go of it, Mr. President.

PRIVATE OPTIMISM - PUBLIC GLOOM
Our friend David Brooks has another doozy this week in the New York Times: the growing gap between our private optimism and our public gloom. Sounds like Garrison Keillor and Lake Wobegone, but he says we're more pessimistic about our national ability to solve problems than we were at the height of the Viet Nam War/Watergate/Energy Crises in 1974. "Voters don't believe government can lift their standard of living or lead a moral revival. They want a federal government that will focus on a few macro threats - terrorism, health care costs, energy, entitlement debt and immigration - and stay out of the intimate realms of life. They want a night watchman government that patrols their streets at night but stays out of their homes," says Brooks.

CHENEY ATTACKS DEMOCRATIC PLAN TO REVAMP TAX CODE
Everyone intends to be relevant until the bitter end. Congressman Charlie Rangel, who made the mistake of calling his plan "the mother of all tax proposals," welcomed the vice-president's characterization of his proposal as "the mother of all tax hikes." Cheney allowed as how he loved the part of the Rangel plan that reduced the marginal tax on corporations from 35% to 30.5%.

BENAZIR BHUTTO BACK IN PAKISTAN
Those of us who have come to love and admire former Prime Minister Bhutto, and consider her a good friend, are deeply concerned about her journey of faith back to her homeland. Given the political history of the country, and the tragic history of her family and her previous service, one would question her judgment. She insists that timing is everything and now is that time. She has recently expressed to a mutual friend, who talks to her several times a week by phone, that she really is unafraid and believes that she is in God's hands.

ALI MOHAMED GEDI OUT IN SOMALIA
As this east African country once again totters on the brink of total collapse, Prime Minister Ali Gedi checked out after a vote of no confidence in what passes for a Somali parliament. In a country of clans, democratic leadership can only go to the truly powerful and all he had was endorsement by his Ethiopian benefactors. The presence in the country of Ethiopian troops, Islamic militants, and U.S. clandestine involvement serves to further complicate any civilian rule.

TIBET
There was a time in the not-so-distant past that China permitted almost no one into the Tibet they stole from the Tibetans. I was on a visit with fellowship friends to northern Nepal when one of our group stole out in the middle of the night, drove up a boulder-strewn road to the border with Tibet, and walked over large piles of rock into Tibet and quickly climbed back so he could have the joy of having visited. He also had the joy of having to back the truck at least a mile down a narrow mountainous road before he could turn it around. Today we can visit Lhasa, the ancient capital of Tibet, by Chinese train and tourists are transforming its beauty. One Lhasa resident was quoted on Jim Lehrer: "What's there to do when you've sold all your yaks?"

©2007 Ken Catalino, Creators Syndicate

SUBPRIME SLIME
There appears to be a consensus among the nation's financial leaders that we will likely go through boom/bust financial market cycles like the DOT COM and the SUBPRIME SLIME on maybe five-year cycles. Given that some of the smartest people in the world are attracted to the financial services industry, one would think they might be able to predict the cause and effect involved. Not so. At the "smartest" level the financial gains are so large and the losses so comparatively small that the incentives to predict and protect (the rest of us losers) are now gone.

PEPPER COMMISSION
I agree with most of what the Alliance has to say about the unique efforts made by all of us who served on the Pepper Commission. Two reservations: (1) Seven of the eight members including me did not agree with the concluding statement that universal coverage is too important to wait until health care costs are controlled.; and (2) When the chair's insistence that we vote on an employer play-or-pay proposal for universal coverage passed 8-7 with Dems and GOP divided, this set the stage for the de-bi-partisanizing of health policy engagements in Congress and elsewhere.

The Alliance for Health Reform has made the entire Pepper Commission Report available online. Visit their website for more details and to read the report.

2007 James L. Reinertsen Lecture
Overtreated: Why Too Much Medicine is Making Us Sicker& Poorer
November 15, 2007, 4:30 - 8 PM
Minneapolis, MN
During this lecture, award-winning author Shannon Brownlee will discuss her new book, Overtreated. There will be an hors d-oeuvres reception preceding Ms. Brownlee's lecture, as well as a post-lecture dessert reception. The event will take place in Schulze Hall on the University of St. Thomas's Minneapolis campus.

This is event is co-sponsored by the Institute for Clinical Systems Improvement, The National Institute of Health Policy, and Minnesota Community Measurement.

Please visit our website for further details.

Aiming High for Health Care in 2008: Showcasing Patient-Centered Alternatives
The Citizens' Council on Health Care's 6th Annual Health Care Policy Event
November 15, 2007, 8:00 - Noon
"Next year, 2008, will be a critical year in health care - in Minnesota and in the United States. Come hear national experts share their perspectives and patient-centered, free-market strategies for health care in 2008 - and beyond." Visit CCHC online for more information.

NCQA's 2nd Annual Public Policy Conference
December 6, 2007
Washington, DC
"This one-day conference will bring together the innovators shaping answers to such questions as why we need the medical home concept, how we can improve the quality of care and who will pay for this new approach." Visit NCQA's website for more information.

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