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Saturday, April 26, 2014

Least Costly Alternative Is Not Necessarily Best Treatment

MedPAC recommendations miss the mark

During a recent meeting of the Medicare Payment Advisory Commission (MedPAC, the panel that advises Congress on Medicare policy), proposals put forth could compromise care for millions of Medicare beneficiaries.
Of particular concern is applying "least costly alternative" or "comparative effectiveness" standards in Medicare policy, which would shove patients into "one size fits all" Medicare decisions made in Washington.  Under this scenario, if federal officials at Medicare decided that one treatment (for example, a drug, device or surgery) is close enough clinically to another treatment, Medicare payment would be set at whichever treatment was cheapest.
On paper, basing reimbursement on the cheapest available could be perceived as a great way to save money. With financial insolvency projected for the year 2026, Medicare needs to achieve cost savings in order to strengthen its own sustainability. So why not simply set reimbursement levels at the lowest possible level?
In practice it puts Medicare policy in between doctors and patients and takes away doctors' ability to tailor care to the needs of each patient. Without the ability to tailor care to meet their individual patient's needs and preferences, doctors and hospitals must either prescribe the cheapest treatment or pass along the costs of a more appropriate treatment onto the patient. These inherent problems are widely recognized by those, who understand from experience, that their needs are different from other patients with the same condition. In a recent poll conducted by the Partnership to Improve Patient Care (PIPC), respondents overwhelmingly rejected these types of proposals that would allow a government agency to determine which treatments were "best" based on "one size fits all" judgments.
Maybe this could work in a world in which all human beings were identical in their body chemistry, genetic makeup, and health status, but in reality, our population is comprised of an infinite array of genetic and molecular combinations. Consequently, one person might achieve better health from a particular medicine while his or her neighbor may see no health improvement, or even suffer side effects.  This is particularly true for the Medicare population. More than half of those 65 years or older have five or more chronic health conditions, of varying degrees of severity. In treating these patients, physicians painstakingly determine which combinations of medicines, will be most effective in controlling symptoms and enabling healthier lives. By limiting coverage to treatments deemed to be the "least costly," these patients may face barriers and additional costs when seeking the combination of treatments that works best for them.
The "least costly alternative" proposal is just one example of this issue. Patients will face the same challenge as CMS uses its current authority to pursue "bundled payment policy" that relies on rigid treatment protocols and care pathways to achieve savings. This policy operates on the same principle - assume treatments are equal on average and ignore wide variation in patient needs. In a recent Clinical Cancer Research journal article, leaders in the cancer community highlighted concerns with these types of policies, saying that these "approaches, which relied on static, point-in-time evaluations based on broad population averages, seem to be particularly challenged by the emerging science in oncology, by the growing emphasis on patient engagement and patient centeredness, and by the new era of personalized cancer care that these changes are driving." 
The MedPAC discussion raises a pivotal question - should saving money take precedence over prescribing the most effective treatments?  Should we even have to ask that question? Wouldn't it be far preferable to have a serious national discussion about ideas that could bring greater value and cost-effectiveness to Medicare without denigrating the quality of care patients receive?
We could certainly make Medicare a stronger program, in a financial and healthcare sense, if we invested in early interventions and innovative therapies to attack chronic disease, spending relative pennies to keep people healthy instead of large dollar amounts to treat symptoms that have exacerbated.  In fact, a number of care models, such as patient-centered medical homes, intensive monitoring and care coordination for patients after they leave the hospital, and chronic care self-management are making a difference in both lowering costs and improving outcomes. 
We cannot achieve a healthier society simply by making investments based on what is the cheapest. No patient wants to, or should, feel squeezed into a "one size fits all" treatment plan. MedPAC's proposed "least costly alternative" policy is the wrong policy in the wrong place at the wrong time. 
Thorpe, Ph.D., is chairman of the Partnership to Fight Chronic Disease (PFCD) and a Robert W. Woodruff professor and chair of the Department of Health Policy & Management in the Rollins School of Public Health at Emory University, Atlanta, Georgia. He also co-directs the Emory Center on Health Outcomes and Quality. He was deputy assistant secretary for Health Policy in the U.S. Department of Health and Human Services from 1993 to 1995. 

Slave Mentality Continues To Effect Jews Around The World.

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The Slave Mentality’s Long Shadow
By Sara Lehmann
The Jewish Press
April 11, 2014
Aside from the clich├ęd quip about Pesach (Passover) preparations mirroring Jewish labor in Egypt, a concept I can well relate to, Pesach is universally regarded as the Jewish holiday of emancipation. The precept of Zeman Cheiruseinu (Season of our Liberation) is so fundamental to our Jewish identity that it is not consecrated solely on Pesach but is repeated throughout the year in much of our davening, berachos (prayer and blessings) and practices.
This idea of Jewish independence from other nations and dependence on Hashem (G-d) alone has guided Jewish thinking and influenced humanity as to the innate worth of the individual. And it is a reason so many Jews have found themselves at the forefront of liberation movements over the years.
Which is why the abandonment of this course by many Jews nowadays is so baffling. Despite the enormous accomplishments of their people, in Israel and elsewhere, some Jews seemingly find it difficult to recognize their own sovereignty, frequently bowing to foreign gods rather than to God.
In his renowned 19th century commentary on the Haggadah, Rabbi Dr Marcus Lehmann offers a description of this phenomenon that eerily portends present-day realities. “It is a historical fact,” he writes, “that slavery produces a slave mentality…. The slave still remains a slave when his shackles are finally sundered. Even if the Israelites had been freed from the servile yoke of Pharaoh and Egypt by some political upheaval, they would have long since lost the capability of becoming a free and noble nation. Therefore the Haggadah rightly says that if God had not freed us, then we and our children and our children’s children would still have to bear the servile yoke of Pharaoh, even when Pharaoh and Egypt had long ceased to exist.”
Despite the exodus thousands of years ago and our break from the ghettos hundreds of years ago, the slave mentality follows us like a long shadow.
Israeli leaders since 1967 have exhibited that mentality in their continuous pandering to contemporary taskmasters at the expense of their Jewish brethren and homeland. Oslo, the Gaza Disengagement, “Peace” negotiations and prisoner releases all point to a deteriorating pride in Jewish heritage and identity.
And the mentality is not limited to Israeli leaders. (Think AIPAC, American Israel Public Affairs Committee, in particular) How else can one explain the subservient attitude of Jewish leaders in America who year after year kowtow to whatever administration happens to be in power? During one of Obama’s humiliating foreign policy faux pas this year, he succeeded in rustling up high-profile U.S. rabbis and Jewish leaders to petition Congress to authorize American military intervention in Syria. (This against the better wishes of the American public and at a time when the Israeli government was trying its best to maintain silence and neutrality.)
More recently, American Jewish leaders did an about-face on the Iranian threat. At Obama’s behest, they ceased lobbying Congress for support of the Iran Sanctions Bill after America’s disastrous November capitulation to Iran. They furthered this ignominy by using every creative way possible to avoid discussion of the topic at the recent AIPAC convention.
Perhaps the most egregious aspect of Israel’s prisoner releases is that they constitute an elemental affront to Jewish decency. No other government prides itself on such intense loyalty to its citizens on and off the battlefield yet simultaneously mocks that fidelity in a warped political farce aimed at placating world leaders. And Netanyahu’s latest refusal to release the last batch of Palestinian prisoners was less a defiant unburdening of American shackles than a grudging recognition of the binding shackles of his own political coalition. One member of that coalition, Deputy Defense Minister Danny Danon, has been the government’s Jiminy Cricket, condemning further prisoner releases and threatening to resign if a release goes through.
I spoke with Danon last week, and even with John Kerry scrambling to clinch a deal by throwing in the sweetener of a Jonathan Pollard release, Danon was not budging. “I have been fighting for Pollard for the last twenty years,” he said, “and I continue to fight for him to come back to Israel. But I don’t think we should make a linkage. Even if Pollard will be released I will still resign as deputy minister of defense. This is a moral decision. We should not allow murderers to walk freely.”
Danon condemned Kerry’s shuttle diplomacy as “unacceptable” and lamented how “in the past Netanyahu said there will be no pre-conditions and then we saw that a settlement freeze and releasing murderers became pre-conditions. Even now we are negotiating about the price to continue to talk. We need tell our friends in the U.S. that there are red lines that we are not willing to cross.”
Is it mere coincidence that these negotiations, which serve only as a vehicle for Jewish self-immolation, are unraveling at a fast and furious pace as the holiday of our redemption approaches?
The lessons of Hashem’s deliverance of the Jewish people became all the more crystallized when I heard Danon admit he was “very concerned” about Kerry. “He is adopting the Palestinian ideology and talking about two states and two capitals in Jerusalem, meaning that we have to go back to the 1967 lines.”
Danon’s solution? “We should count only on ourselves, despite our friends in the Jewish community and in both houses of Congress. Israel is preparing itself for all options, even the option of dealing with the threat of Iran by ourselves.” (And … let us say, Amen)
Welcome words from a politician whose ascent in Israeli politics is not accompanied by selling out the citizens he represents. Coupled with reliance on Hashem, this should be a wake-up call to other policy makers who suffer from an affliction of Jewish insecurity that threatens the security of us all.
About the Author: Sara Lehmann, a freelance writer living in Brooklyn, was formerly an editor at a major New York publishing house.
Jsk Addendum: This painful but brave and factual article brings to my mind a beautifully descriptive, newly coined Hebrew word — “Mamlachtiyut”

Mamlachtiyut, a neologism (The invention of new words regarded as a symptom of certain psychotic disorders which eludes English equivalents but which, in this case, roughly translates as “ The ability to act in a sovereign-like manner,” thus employing and preserving a nation’s power).  
By mamlachtiyut, Ben-Gurion meant the Jews’ ability to handle power — military power as well as democratic and political power — effectively, justly, responsibly.  The Jews of Israel, Ben-Gurion knew, might succeed in repelling Arab armies, in absorbing many times their number of new immigrants, and in creating world-class governmental and cultural institutions, but without mamlachtiyut, without the ability to deal with power and take responsibility for its ramifications, they could not ultimately survive.

The above Ben Gurion quote is from former Israeli ambassador to the US, Michael Oren 2006, who himself suffers from a lack of mamlachtiyut, as he continually recommends that Israel give up Judea and Samaria to the Arabs – a virtually guaranteed step toward Israel’s ultimate self-destruction, Hashem forbid.
Jerome S. Kaufman
Twitter: @israelcomment
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Federal Reserve Is A Two Trick Pony And The Poor Animal Has Run Its Course.

Hussman: The Fed Has Built a 2-Legged Stool

Tuesday, 22 Apr 2014 10:02 AM
By John Morgan
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The Federal Reserve is resting the fate of the U.S. economy on a two-legged stool by focusing only on jobs and inflation, while financial excesses are left unchecked, according to Fed perma-critic and mutual fund manager John Hussman.

In his weekly market commentary, the founder of the eponymous Hussman Funds predicted the Fed has baked unavoidable consequences into the cake of massive monetary stimulus that will prevent its employment and inflation goals from being met.

"Make no mistake. The Federal Reserve's policy of quantitative easing has starved investors of all sources of safe return, provoking them to reach for yield in more speculative assets, including equities, leveraged loans, covenant-lite debt and other securities," he wrote.

"Having stomped on the pedal for years, all of these asset classes are valued at levels that are strenuously elevated from a historical perspective, and as a result, offer strikingly poor prospective returns for long-term investors."

Hussman noted also the 2000-02 stock market decline wiped out every shred of S&P 500 total return, "in excess of Treasury bill returns, all the way back to May 1996," and the 2007-09 decline eliminated "every bit of the market's excess return all the way back to June 1995."

There is no economic law that says the current bull market must likewise end in a dreadful plunge, he acknowledged.

"On the other hand, I have no doubt at all that having driven equity valuations to present levels, investors will be starved of total return — from current prices — for at least a decade (assuming valuations never move below historical norms), and possibly much longer (in the event that valuations do indeed move below historical norms 15 or 20 years from today)."

According to Hussman, it is too late in the current bull market for the Fed to unwind the policies that led to "malinvestment" and extreme valuations, but there may still be a way to manage the downside for the broader economy.

"Oversight – particularly in leveraged equity, leveraged loans, and covenant-lite lending — should be far higher on the [public] agenda than promoting further overvaluation and speculation, in the hope that some small benefit will trickle down to the masses," he said.

Michael Feroli, JPMorgan Chase's chief economist, believes the Fed is faced with an "impossible trinity," Bloomberg Businessweek reported.

In an essay, Feroli predicted that three things cannot possibly co-exist in the Fed — transparency, collegiality and clarity. While the Fed is striving to achieve all three, he says that will soon be demonstrated impractical because the Fed members do not agree on how to control inflation and asset bubbles.

In a guest column for Forbes titled "The Bizarro World of the Federal Reserve," contributor Mark Hendrickson questioned why the Fed has been so intent on achieving a higher level of inflation to spark the economy.

"I guess it's because I've always thought that the purpose of a central bank is to defend the soundness of its country's currencies, not to depreciate it. How quaint and naive of me," Hendrickson wrote.

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Employer Provided Health Insurance Will Soon Become A Thing Of The Past

Krauthammer: Obama's Plan is to Semi-Nationalize Healthcare

Tuesday, 22 Apr 2014 09:16 AM
By Melissa Clyne
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Obamacare’s endgame is the semi-nationalization of American healthcare, syndicated columnist Charles Krauthammer said on Fox News’ "Special Report with Bret Baier."

"What the real objective of Obamacare is is to sever the relationship that people have now with employer-provided insurance and with their private insurance and also with the small group insurance so everybody ends up in the market, which is essentially controlled by the federal government," Krauthammer opined. "It is a semi-nationalization using the insurers as the middle man. But that’s what it’s about, and that was the objective in the first place, and that’s why all the numbers are obscure, all the numbers are hidden, and why you’ll only get them after we kick and scream and demand them."

Evidence of Obama’s objective can be found in a Congressional Budget Office report projecting that half of the 25 million people who have signed up for healthcare insurance will lose their existing coverage after 10 years of Obamacare. The CBO states that by 2024 there will be a net gain of 13 million who become insured, but 31 million who will be uninsured, according to Fox News.

Speaking at Cornell University last week, Krauthammer characterized Obamacare as a "clumsy beast" and said President Barack Obama made a fatal mistake by signing a law supported solely by Democrats, compared with programs such as Medicare, Social Security, and Medicaid, which had support from both sides of the aisle, according to a piece in the Cornell Chronicle.

The decision has resulted in a "terrible liability" for Democrats, according to Krauthammer, who predicted that the president’s signature healthcare reform law will be short-lived.

"Obamacare is such a clumsy beast that it will simply expire … and then the country’s going to have a true choice between a single-payer system … [and] a free-market system," he said.

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TSA And Federal Air Marshall Service In Illegal Gun Selling Operation. Don't You Just Love Big Government!

Report: Key Figure in Gun-Selling Probe Signed Deal With TSA

Friday, 25 Apr 2014 11:10 PM
By Todd Beamon
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The outgoing head of the Federal Air Marshal Service has signed an agreement that would suspend any disciplinary action that might result from an ongoing investigation into an alleged illegal gun-selling operation within the agency, Fox News reports.

Robert Bray, who is quitting in June after directing the service for nearly six years, signed the agreement with the Transportation Security Administration. The TSA oversees the marshal's service, Fox reports.

The deal was disclosed in an April 18 letter by TSA chief John Pistole to North Carolina Rep. Richard Hudson, the Republican chairman of the House Transportation Subcommittee.

Bray is being investigated for obtaining free guns through the marshal's service without authorization. His Washington-area home was raided by federal law-enforcement officials in December. Bray announced his retirement in March.

"I am aware of the allegations within the FAMS, including those involving the director, and believe them to be subject to appropriate investigation," Pistole said in the letter, which was obtained by Fox. While the investigation was continuing, the letter said, Bray "has entered into a settlement agreement, which includes a provision to hold in abeyance any potential disciplinary actions."

Pistole's letter was in response to a query from Hudson on whether Bray's resignation was linked to the federal investigation, Fox reports.

But Bray's attorney, Ken Cuccinelli, told Fox in a statement that the agreement was reached after his client announced his retirement.

"After nearly 40 years of unblemished service in law enforcement, Mr. Bray announced his retirement on March 31," Cuccinelli said. "Several days after Mr. Bray's retirement announcement, a representative from the TSA Office of Chief Counsel approached Mr. Bray about entering into a mutual hold-harmless agreement in which both sides waived any potential claims against the other and set down the timeline of Mr. Bray's retirement."

According to Pistole's letter, the investigation stemmed from a tip last March to the inspector general's office at the Department of Homeland Security that a "Federal Air Marshal (FAM) was purchasing and selling guns without a license to co-workers," Fox reports.

The DHS office then referred the information to TSA for investigation.
The operation, whistleblowers have told Fox, involved Air Marshal Supervisor Danny Poulos, who now is on administrative leave. He is accused of misusing his relationship with Sig Sauer, the German weapons manufacturer, to obtain firearms at a discount for marshal's service staff.

They included Bray, according to Fox.

While TSA officials have confirmed that Bray had bought weapons from Poulos, he did so legally and with "no knowledge" they may have been "ill-gotten," Pistole said in the letter quoted by Fox.

Bray also admitted to CNN earlier this month that he bought the guns from Poulos, but he denied that his retirement was related to the TSA's investigation.

"I have nothing to hide," Bray told CNN. "I'm not trying to hide anything."

A TSA spokesman declined to comment on Pistole's letter to Fox.

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