Support the Fiscal Commission

If you live in MT, CA, MI, OK, ND, ID, IL, NH, TX, WI or SC, look at the list below:

Sen. Max Baucus (D-MT)

Rep. Xavier Becerra (D-CA 31)

Rep. Dave Camp (R-MI 4)

Sen. Tom Coburn (R-OK)

Sen. Kent Conrad (D-ND)

Sen. Mike Crapo (R-ID)

Sen. Richard Durbin (D-IL)

Sen. Judd Gregg (R-NH)

Rep. Jeb Hensarling (R-TX 5)

Rep. Paul Ryan (R-WI 1)

Rep. Jan Schakowsky (D-IL 9)

Rep. John Spratt (D-SC 5)

These are the names of the elected lawmakers who sit on the National Commision on Fiscal Responsibility and Reform.  There are also non-elected members, to round out the members to 18 total.  Looming is a Dec 1, 2010 deadline for the commission to have 14 of the 18 support the commission's recommendation to the President.  If the commission cannot get support from 14 of the 18 members, a formal report will not be released.

If the commission can make formal recommendations, it will be much harder for our lovely politicians in Washington DC to continue to avoid this hot potato issue. 

See two other posts I've written about the commission and their draft recommendations:

Shared Sacrifice 11/14/2010
Well, It's a Start  11/29/2010

Even if you don't like the commission's recommendations (which no fiscal responsibility initiatives are ever going to be wildly popular) I urge you to voice support for the commission to release a formal report.  If you live in one of the states above, please contact your Senator or Congressman to tell them to support the commission report. 

We need candid and aggressive discussions and debate to come to a set of solutions for our deficit.  We need to act now, and stop ignoring the elephant in the room.

Well, It's a Start

Today the President announced a proposal to freeze salaries for non-defense civilian federal employees for 2 years, beginning with 2011.  The announcement came as a bit of a shock to liberals, and a slap in the face  unions, historically strong Democratic supporters. 

The idea is not a new one, as short-lived salary freezes are used commonly during times of financial stress in the private sector.  And arguably the private sector has been under a "salary freeze" if not a "salary decrease" cycle since the start of the Great Recession. 

The idea is also not truly the President's either.  Almost 3 weeks ago, the chairs of the President's Fiscal Commission (Alan Simpson and Erskine Bowles) released their draft plan for deficit and debt reduction, which included the idea the President advocated today, as well as many others, aimed at reducing the federal deficit, and the growth of the federal debt.  I summarized previously - take a look.

Despite the President's near alignment with what most people would categorize as a Republican position, even Republicans were not without complaint today.  Politico, in an article published today, quoted a Repulican aid as saying "If he wanted to work together, he could’ve called up and did something jointly.

I think if the president is willing to focus on the issues Republicans trying to champion, I think Republicans would welcome that and join in a partnership.”  While not complaining directly, the aid is voicing some GOP frustration.  The President is taking this position a day before a planned White House meeting with Congressional leaders, allowing him to take credit for the initiative himself, without appearing to be reaching across the aisle. 

 

To me, the President coming out with this idea without first working collaboratively and publicly with Republican leaders is not surprising at all.  The President's support of this idea will irritate his base enough all by itself - I'm sure the President doesn't want to further irritate by doing it in open collaboration with the opposition party. 

 

While it's a start in the right direction (starting to put some costs controls in place), we're talking about a relatively symbolic gesture (that is still subject to Congressional debate and support - or not).  With a mere $2 billion in savings in 2011, and a 10-year cumulative budget impact of just $60 billion, it's really just a drop in the bucket.  The federal budget contains more than $3 trillion in spending annually.  $2 billion in 2011 is a reduction of just 0.067%. 

 

If you look at the Fiscal Commission's draft proposal, you'll find a couple more areas of federal spending related to federal empoyees that come under fire.  The Fiscal Commission advocates a 10% reduction in the federal workforce, through a 2-for-3 replacement rule, for a net savings of $13.2 billion by 2015.  This would be not a hiring freeze or reduction in force (as is more common in the private sector) but instead a focused re-hire program that would likely force justification of replacement positions across most, if not all federal branches. 

 

Also targeted by the Fiscal Commission co-chairs is the army of staff-augmentee contractors.  From 2002 through 2005 more than 2.4 million contractors were added to the federal payrolls.  This was arguably a reaction to the reductions in the federal workforce experienced in the 1990s.  The commissions recommendation would be to take a wholesale inventory of all contractors and their roles/responsibilities, followed by a reduction of 250,000 contract positions.  This initiative is estimated to offer savings of $18.4 billion by 2015.

 

The commission offers approximately $200 billion in illustrative savings, but that is only part of the plan.  The commission, in addition to budget cuts in both domestic and defense spending, recommends major reform to the tax codes, additional healthcare reforms (not included in the health care reform bill earlier this year, which did more to expand coverage than to control costs), mandatory savings from farm subsidies, military and civil servant retirements, and even changes to Social Security.

 

The question is, why would the president take aim at federal employees when the goal should be Shared Sacrifice?  Why not come out in support of more of the commission's ideas at the same time, which when combined would have a larger impact on federal spending?  It would seem wise to show a broad dedication to deficit control, spreading the sacrifice among multiple groups. 

 

But, though I often disagree with the President and his politics, I will give him credit for supporting something that will actually have a positive impact.  Maybe it's a sign of things to come - or we can hope.

 

 

 

 

 

GOP Health Care Mandate?

A recent poll, conducted by McClatchy is being headlined as follows: New Poll undercuts GOP claims of midterm mandate.   This appears to be a reaction to the posturing the speaker-of-the-house-to-be John Boehner and other GOP leaders have been doing since successfully recapturing the House majority in the mid-term election.  I've touched on the impact of the GOP House results before.

Here are the top 3-reported results in a graphical presentation:

I'll focus on the health care reform portion of the poll.  Overall, not incredibly insightful results.  810 registered voters were involved, and the stated margin of error is +/-3.5%.  Assuming the health care "unsure" group stays the same as reported (which 5% of everyone seems to be unsure or uneducated in almost every poll, no matter the subject involved), it would appear the keep and repeal groups are basically the same size, given the margin of error. 

The release goes on to claim that voters want to keep the more "popular" parts of health care reform, like barring insurers from denying coverage for pre-existing conditions (59% in favor, 36% against), extending child coverage to age 26 (68% in favor, 29% against), and closing the Medicare Part D "donut hole" (for my previous explanation of this point, click here).  Those analyzing the poll results also claim voters don't like some other parts of the law, like an individual health care insurance mandate (65% claiming it is unconstitutional, 29% in favor).  For purposes of this discussion, we'll assume that someone who responded in the "unconstitutional" category was "against" the mandate from a personal opinion perspective, though technically someone could personally support the mandate from a policy perspective but also believe it technically unconstitutional.

So, if you boil it down, those polled apparently, at a rate of 2-to-1, want to have their cake and eat it too.  All of the "popular" aspects of the law (costs) are supported, while the parts of the law that (arguably) make it work financially are opposed.  Specifically, the individual mandate (which helps ensure that people don't wait until they're sick to seek coverage) is necessary to attempt to balance the acceptance of individuals without pre-existing coverage restrictions.  Realistically, you can't have one without the other, but the poll results appear to show that Americans are more interested in an ala carte approach.  Seems the majority of those polled would like to skip their vegetables and fill up instead on fat and sugar-filled dessert.  Given the state of health in our country, this seems to fit.

As I've stated in a previous blog post, it's extremely unlikely, despite the posturing of the GOP leadership, that the health care reform law will be repealed in full.  With a divided Congress, and an Obama White House, wholesale repeal is not a realistic or achievable goal for the GOP.  However, I believe it is dangerous to consider partial repeal or weakening of these less popular aspects fo the law, while leaving the more popular aspects unchanged or strengthened.  In the end, the health care law was about cost (as is almost everything Congress involves itself in) and if Congress were to bend to the popular opinion, we would further endanger our country financially, undermining other efforts underway to find ways to improve the long-term financial stability of our country. (not to mention that such changes would destabilize and destroy current health insurance)

As for the question of a mandate for the Republicans in Congress, I fail to see any aspect of a mandate for the GOP.  Republicans captured only the House, and the Senate remains in Democratic control.  I would say we instead saw a mobilization of portions of the Republican base (and a lack of inspiration for the Democratic base) mixed with a healthy dose of general dissatisfaction with the slow economic recovery orchestrated by the Democrat-weighted Congress..  A Republican claim of a mandate is purely posturing.  So, despite a lack of hiding partisan bias in the presentation of the poll results, the McClatchy headline is, I suppose, technically correct...

Bad Economy Means Clearer Skies

A study published in the journal Natural Geoscience shows something amazing - Worldwide carbon emissions DROPPED 1.3% from 2008 to 2009.  The drop in emissions was much higher in some specific geographic areas like:

US - (6.9)%
Germany - (7)%
Russia - (8.4)%
UK - (8.6)%
Japan - (11)%

Certain parts of the world still saw dramatic increases in carbon emissions -

India - +6.8%
China - +8%

The drivers of the drop in emissions include efforts to reduce emissions, investment in "green" technology, a worldwide reduction in deforastation, and... get this...  the global recession.

That's right, a poor economy is helping the earth.  The lead author of the study confirmed that the drop in emissions was directly related to the global recession.  "There is a close link between the world's gross domestic product and emissions of carbon dioxide," says Pierre Friedlingstein of the University of Exeter in the United Kingdom.

As the world's economy recovers (for some) as expected, it is also expected that the growth of carbon emissions will again grow by more than 3% from 2009 to 2010. 

So, finally we have a positive out of the bad economy.  And if Washington doesn't act soon on the pending tax increases coming Jan 1, 2011, or the balooning federal debt, we could see the US carbon emissions drop again in the future.  Good for tree huggers - Bad for everyone else.

Boehner Pledges to Fly Commercial

Previously Republicans have attacked Nancy Pelosi and her use of an air-force jet for travel between Washington and her home district in California - not because of the use of the jet itself, but for the size and lavishness of the supposed jet requested.  In early 2007, due to security risks cited by the House sergeant-at-arms, there was discussion about "upgrading" the jet used for Speaker travel, to allow Speaker Pelosi to make it between DC and California non-stop.  The jet used by the previous speaker, a govt version of a Gulfstream jet, sat 12.  The jet apparently requested at the time was a govt version of a 757-200 with seating for 45 in business class, along with a stateroom, conference center, communications center...  Basically the type of aircraft used by the First Lady and the Vice President.  For full details on the debate in 2007, click here. For the snopes.com review of this debate, click here.

Recently, as John Boehner prepares to assume the role of Speaker of the House, there has been renewed discussion on Speaker travel.  Here's Boehner's stance on it:



While Boehner's position is in line with the government fiscal responsibility position he and other Republicans have been talking about, his stance of continuing to fly commercial from Washington to his home district may be more show than substance.

The fact of the matter is that the Speaker of the House sits right behind the Vice-President in terms of succession.  I can't imagine this country, post-9/11, allowing such a high-ranking elected official traveling commercial on a regular basis, especially when on official business.  Security protocol shouldn't allow it.  In fact, even the Bush White House, when presented with the debate in 2007 over Pelosi's use of military aircraft commented:

"As Speaker of the House, she is entitled to military transport and... We think it's appropriate. And, so, again, I think this is much ado about not a whole lot.  It is important for the Speaker to have this kind of protection and travel," said White House spokesman Tony Snow, at the time.

I would guess that, given a little time, this pledge of commercial flight will morph into only applicable to "personal" flight.  The future speaker seems to leave the purpose of the travel he references out of his comments.  For government business, it would make a lot of sense to have him travel on military aircraft. 

Plus, I'm sure Boehner would prefer not to be felt up everytime he heads to and returns from Ohio.

A Few Thoughts On TSA Pat-Downs & Those Vocal About Them

For all those out there concerned about your "junk" and the TSA's sudden interest in said "junk," I have a few unsolicited thoughts.

First, the physical, digital (meaning with hands and fingers, not referring to data with 1s and 0s) inspection of your nether region is a choice you actively choose to make, completely independent of any  outside force. You are free to choose to be inspected by the new scanners, if selected for such review (most airports, if not all, have too few scanners to screen all travelers with this method, even if they were permitted to), or you may choose a pat-down. The choice is pretty much yours.

Second, despite what your crazy fantasies have shown you, the TSA TSOs are no more thrilled with feeling your jewels than you are. Despite your suspicions otherwise, the inspections of the land between your legs likely wasn't in the job description they saw when they were hired, and like a gynecologist, after the first few peeks under the gown, it's a job... and in some cases, one most of us really wouldn't want.

Finally, yes, as you are so loudly shouting, the x-ray or pat review of your package is likely not terribly effective, and we should be more closely examining the packages in the cargo hold as well as the one in your jeans. The bad guys who wish to do us harm are always two steps ahead, and know our security better than we do. They're already thinking up new, and creative ways to attack us that we would likely never detect, even with our most advanced technology (which I already admitted is not even yet fully deployed).  Still, it's my humble opinion that a moment of anonymous ogling (by someone who is already, just a few days in, sick of looking at "naked" fat Americans) or, if you choose the hard way, a healthy clothed inspection of Jim and the twins, in the grand scheme of things is better than being sucked through a newly blown hole in the side of a jet. 

Mostly, my message is, get over yourself. If you don't like it, tell your Congressman, and vote accordingly. Until then, realize it's unlikely you have anything memorable to view on x-ray or feel through your chinos, so stand there, smile, and move onto your gate. The sooner you get on your way, the sooner the 350lb 4'10" man behind you (who will likely be your seat-mate during your flight) can get his thrill for the day, and the TSO involved can write his resignation letter.

Fixing Costs of Health Care - Part 2

Continued from Part 1

Let’s go back to our little button from Part 1.  Imagine that our button is one of many buttons, because the button/dial administration is giving them out to anyone who asks for one, no matter if they have any chance of hearing a bell or not.  Well, it’s now becoming common knowledge that no-one is really paying any attention to the button pushing.  It’s also becoming common knowledge that dial-turning is really getting watched closely.  In fact, the button/dial administration is really cracking down on dial-turners.  If you’re caught doing that, you don’t get a Christmas bonus.  The dial-turners are getting scared (they promised their family an in-ground pool), and they want to get out of the dial-turning business and get into something safer, with lesser penalties for getting caught. So, the dial-turners, who are organized by the way, start asking for buttons, and set them up.    

Back to the real world (getting dizzy yet?), and the same thing is happening.  Organized crime is real.  Illicit drugs, as an example, have been a nice tidy revenue stream for these groups for some time.  But life for drug dealers and suppliers, because of things like the War on Drugs, is getting a little harder (I didn’t say the War on Drugs was completely ineffective).  Not impossible, mind you (remember the cockroach analogy?) but harder.  Many are finding that health care fraud schemes are just as profitable, without as much risk of being shot by a competitor, and with more limited sentences for convictions.  Oh – and for years, almost no-one was watching.  So, if you’re a criminal looking for an easier row to how, take a look at health care fraud.
But fraud is only a portion (though a big portion) of the issue associated with the fee-for-service payment system in health care.  There is also an embedded fatal flaw in the core idea of incenting providers and suppliers on a volume basis.  Through fee-for-service systems, we reward “doing” more, even if the more that is being done is unnecessary, is of lower quality than we would expect or want, or is more expensive than an alternative that may be just as, if not more effective than the more being done.  

It’s certainly logical, in any endeavor, to pay for products and services that are both valuable to the consumer/stakeholder and are not readily or easily available/doable on your own.  I am glad to pay someone a reasonable amount to do things like repair my vehicle, fly an airplane I’m using to reach a far off destination, or provide my home and my family with clean, running water.  These are things that I personally do not have the expertise, time or desire to do for myself, and so I gladly give portions of my hard-earned money to others for these acts and products.  The same goes for medical care.  I’m happy to provide funds to someone else to help me by providing diagnostic services when I’m ill, provide me medications that are needed for my conditions, or even perform surgery when it is needed.  

What is not logical is to establish and then support a system where the services are paid for whether they are needed or not, and no matter the outcome of that service.  For example, when I take my car into the mechanic for an oil change, I don’t want to pay for a new transmission if I don’t need one.  If I board a plane to Atlanta, I don’t want to find out that I’ll also be paying (extra) for a stop over in Detroit that I don’t need (or want for that matter).  And I want clean water in my home, but I would not want to pay the utility company if my water is constantly brown, and makes me sick because of contamination.

The same is true for health care.  We want to get better, or, better yet, prevent getting sick.  For those services, it is logical to pay.  However, if, in the process of “getting better” or “preventing illness” we are subjected to service, treatments or medical products that do not help us along the path to wellness (or actively make us more sick), and we are asked to pay for those things, then we have a problem.

So, by using fee-for-service, we have fraud, which will admittedly be present in any system, but is more prevalent in a system that makes it easy to bill, pays quickly, and has so much volume that it’s easy to slip below the radar.  We also have a perverse incentive to drive volume of work versus quality of work.  We can potentially, through enforcement efforts, keep fraud in check to a certain degree.  We cannot, however, eliminate the fatal flaw in how we incent payment without major overhaul.

We must come up with a system for payment in the health care industry that reduces or eliminates the incentive to just do “more” and replaces it with incentives to do what is “right” for the patient and actually “works” to accomplish our end-goal of health.  I actually propose we start at the end of the process and develop backwards.  Our end goal in health care is (or should be) to improve or preserve health.  So, let’s use health status of a patient as a criteria marker for payment.  In other words, pay for medical outcomes.

Instead of paying for services, on a negotiated fee schedule, pay for improvements in conditions.  If I am diagnosed with high blood pressure, why not pay my health care provider when my blood pressure goes down?  If I am diagnosed with diabetes, why not pay my health care provider when my Hemoglobin A1C is brought into a normal range?  Take established and accepted treatment goals, and incent health care providers to help the patient reach those goals.

In the same vein, think about paying primary care physicians based upon the health status of their patients overall, instead of based upon how many encounters they have in their medical office.  Instead of “visits” they are paid on “wellness.”      

I would suggest we pay handsomely for helping patients reach aggressive goals, and pay very poorly for working at it and yet failing to have patients “get there.”  At the same time, to engage patients in their own care/health give them an incentive to do their part. I propose you establish cost-sharing schemes that allow the patient to pay less out-of-pocket if they reach their health goals and more out-of-pocket if they don’t.  

Suddenly, you have everyone aligned.  You have health care providers looking at how to most efficiently and effectively get people better, or better yet, keep them well.  Your personal health is now tied to your financial health.  Your person health is also tied to your health care provider’s financial health.  

Hold on – we’re going back to our button…  No-one knew it, but the bell you were hearing was ringing every time a fire broke out somewhere in America.  And your button – well, it turned on the sprinkler system to put out the fire.  Well worth the $5, right?  But, slowly but surely, with all the extra button pushes (yours, your brother-in-law’s and organized crime’s) most of the homes in America are now flooded.  So, realizing they have a problem, the button/dial administration undergoes a radical transformation, and emerges as the fire suppression administration.  They recall all buttons.  Instead, they offer every family in American $10 a week if they do not have a home fire. Instances of home fires drop dramatically. Unfortunately without the extra button income you have to cut back to 2 peppermint mochas a week (using your new fire avoidance allowance).  But fortunately your brother-in-law takes his lovely family, RV and yacking dog home, and the dial-turners decide to investigate widget-making as a new profession instead.

Fraud in health care will never be completely gone.  No matter the system in place, someone will find a way to game it.  At the same time, not payment schema is perfect, and there will always be some illogical aspects.  But, with engaged patients, properly aligned health care providers, and sufficient credentialing (and ongoing audits), I believe the majority of the health care fraud we experience today would be gone, overall health care costs would drop and we’d likely be healthier to boot.

Fixing Costs of Health Care - Part 1

Imagine there's a button on your desk, designed to be pressed every time you hear a bell. And every time you press the button, $5 is deposited in your checking account. You hear the bell every few hours, and you push the button each time.  Looking around, though, you notice that no-one is watching you press the button. Apparently they trust that you are only hitting the button when the bell rings.  But you're a good, honest person... Right?

A few days in, and Starbucks has re-launched their seasonal peppermint mocha.  It's you're favorite. But, expensive gourmet coffee isn't in your budget.  No-one's watching, and you really want that mocha. It's for mental health, right? And you've been loyally pressing that button every time the bell rings... And maybe you missed one while you were in the restroom... So, just to be safe, you hit that button one extra time. No real harm, and you get your mocha.

That peppermint mocha was good. You could use one every day. What's the harm? You hit the button just one extra time each day, except Monday - you need two that day. It's hard to get going on Mondays...

I could go on.  But everyone can likely see where the normal human response might lead to in this hypothetical scenario. Eventually the person here is hitting the button willy nilly and is buried in coffee and muffins. Heck, maybe they have a Starbucks installed in their office, with a personal barista.

What I describe is not very different from the way that the vast majority of our US healthcare payment system is structured. The term in the industry is “Fee-For-Service” which basically means the payer makes payment to a healthcare provider every time they bill for a service - or every time they hit the button.

But, doctors are good people, right? They go to school for a long time. They have patient best interest in mind (usually – or so we hope). They treat us when we're sick, and help us get well. We like them.

So, what's the problem here? Doctors should be paid for what they do and know, right? Would anyone argue that doctors should be paid for their services? But, doctors are people.  And just like the button situation, they get paid for services – so the more services you do, the more money you make.  Mix normal human tendencies with cost pressures (think liability insurance to protect against lawsuit) and you have a mixture ripe for problems.

And let me be clear, fee-for-service in healthcare is not just limited to doctors – it’s the basis for payment for all healthcare providers and suppliers.  The more you do, deliver, or ship, the more revenue comes in.  In fact, when it comes to risk of fraud, generally providers like physicians are seen in the lowest risk category.  

Now, let’s look at that button again.  Your brother-in-law, who drove his 20 year old RV to your house for Christmas, learns about your button.  He’s a slightly less than upstanding citizen, and he’s been out of work since he left the service, and he blacks out every time the microwave is used, because of the plate in his head… (anyone catch the National Lampoon’s Christmas Vacation reference???) He wants a button too.  Suppose he can get one, and he sits there, hitting the button once every second, racking up huge sums of money.

Back to reality – and we can talk about hitting the button in healthcare – healthcare fraud.  Less than upstanding people, who understand how the payment system works (hit the button, get $$), and they know how to play it -  setup companies to bill for services, don’t actually do them (or do them badly) and make tons of money.  And for a long time, almost no-one was looking.

So, what to do?  There are lots of ideas, some in practice, some not.  

First, you declare war on fraud, which is what the government has done recently.  Huge sums of money are being fed into the healthcare fraud battle to root out and eliminate fraud, waste and abuse.  New contractors, new divisions within Centers for Medicare & Medicaid Services (CMS), strike forces between Department of Justice, Office of Inspector General, Department of Health and Human Services and US District Attorneys and even private-public partnerships (like the National HealthCare Anti-Fraud Association (NHCAA)) are gaining more and more support to combat the “bad-guys.”

But is it enough?  If the War on Drugs (similar to this War on Fraud) has shown us anything, it’s that spending tons and tons of money on enforcement doesn’t guarantee you will quickly win the war.  The enemy is often agile, flexible, and highly motivated.  The enemy in this war always seems a step ahead, and despite spending lots of $ on the battle, they never seem to be eradicated.  They’re cockroaches – they never die, and if you stomp on 1, there are 10 in the wall, waiting until you turn out the light.

To be continued…

Shared Sacrifice

The Republican election-day parties were less than two weeks ago, but they seem like a lifetime ago. With the balloons and streamers cleaned up, and the foggy-headedness of the next day cleared (I'm sure no-one offered any toasts that night) we can get down to training up these new Congress-people so they can take on the world in January. And they will be taking on some pretty tough issues.

One of the issues of the day, and decade, and for all time is the federal debt. Our federal government is currently spending trillions of dollars which we don't really have, and many are waking to the reality that we have many hard financial decisions to make in the very near future to avoid pushing our great nation (and by extension the entire world) into a financial crisis situation.

Recent economic events will likely keep meaningful budgetary and spending reforms in check for another year or so, but change is coming, and there will be much shared sacrifice.  To see some of the proposals to be battled out in Washington in the coming months, take a look at the "debt commission's" draft proposal. (http://www.fiscalcommission.gov/sites/fiscalcommission.gov/files/documents/CoChair_Draft.pdf)

In this proposal are cuts and reforms that cover both domestic and defense spending, tax reform and Social Security and Medicare/Medicaid solvency. No popular or unpopular governmental program seems to be off-limits, and I argue that we can't afford to protect any project or budget from the surgeon's knife. The cancer of overspending has metastasized to all governmental organs, and we need a whole-body treatment.

Let's briefly hit on some of the more striking (to me at least) changes proposed to get deficits and debt under control.

Defense Spending

-Freeze salaries (civilian and non-combat military) for 3 years.
-Reduce overseas bases by 1/3
-Reform (I read reduced benefits) Tricare (military healthcare)
-Integrate military children into local public schools

Domestic Spending

-Reduce Congressional and White House budgets by 15%
-Freeze federal employee salaries for 3 years
-Cut federal workforce by 10% (through less drastic 2 for 3 replacement plan)
-Eliminate 250,000 federal augmentee contractor employees (non-defense)
-Eliminate earmarks

Defense and domestic spending cuts each account for $100 billion in savings.

Tax Reform

It sure is fun for politicians to talk about tax reform (I mean, who can't support, besides those employed by H&R Block, the idea of simplifying the tax code - and by extension the craziness of the forms) but generally the end result of any tax discussion in Washington results in further complicating the situation versus improving it.  The commission lays out 3 options for comprehensive tax reform. Personally I like their zero plan which takes out all tax "expenditures" (which I believe represent credits and deductions) and establishes a simpler tax rate to be applied without all the gyrations we go through today to "adjust" the income you earn. They then allow for the re-introduction of popular and potentially necessary credits like the child tax credits and earned income credits, but pay for them by actually increasing the tax rates themselves.

As a back-up to the ideas that are proposed, they recommend a third option, which allows Congress to come up with alternative plans, but holds Congressional feet to the fire by "haircutting" tax breaks annually (thereby creating an outcry from the populous) until tax reform is enacted.

Other Revenue

The commission recommends other revenue sources, like increasing the federal tax on gasoline. Raise some tax revenue and incent greener transportation development... PotentiallypPretty smart. (I didn't say popular)

Medicare

The Doc Fix proposal is to, well, not fix it... The proposal is to pay doctors less, increase incentives for quality and efficiency, and introduce tort reform to reduce liability expense for providers.

Additionally, the proposal includes generally increasing cost-share borne by Medicare beneficiaries to promote consumer engagement in healthcare decisions. The idea is to make sure people buy healthcare like they do other consumer goods - by seeing and feeling the actual price, and allowing consumers to decide the value of treatment for themselves. With the right information available to people, and education to what all that information means, it's something that can work. Think high-deductible health plan in Medicare.

The proposal also aims to increase brand-name rebates in the Medicare Part D space, collecting these from brand-name drug manufacturers. (sounds like we've been at this well before, but the commission looks to go back)

Social Security

Social Security did not escape the commission's eye. The plan here is to gradually increase retirement age to account for people living longer, update the way cost-of-living increases are calculated (there's been no increase for 2 years recently anyway) and increase the % of payroll income subject to withholdings.

All in all, if Congress does everything the commission recommends, just about everyone in America would be pissed off about something. But you know what, maybe that's the way it should be. And maybe, just maybe, our duly elected representatives in that little corner of what used to be part of Maryland will make those hard decisions, throw political longevity to the wind, and do what we need to so as a nation to survive financially. 

We should, as a nation do what we all know we must do to be financially solvent on our own balance sheets. We must spend no more than we earn, and, if we're smart, put something away for the proverbial rainy day. Perhaps of we'd done that over the last few decades, we'd not be in the mess we are today.

PS - I do not necessarily personally like or endorse any of the particular recommendations of the commission. I do support, however, the idea of universal sacrifice, and realize I will end up doing my fair share of it, like it or not.

Christmas Shopping With a Side of Miles

I'm not the only one who thinks the Christmas shopping season starts earlier and earlier each year.  The major retailers are getting into the "spririt" in a big way this year, and they're kicking off their year-end profit season even earlier.  "Black Friday Preview" sales are all over the place - both in-store and online.

I personally don't really enjoy Christmas shopping, though I love getting gifts... :-)  However, online shopping makes it all so much easier and enjoyable.  Add to that the rash of free or reduced shipping this tume of year, and it really doesn't seem worth getting off the couch to go shopping - just boot up your favorite browser (yes, I still use Internet Explorer) and enter that credit card number.

For us, though, we look a little bit closer than just who has the current sale.  It is said it is better to give than to receive.  I can't necessarily argue or validate that, but if you're going to give, you might as well get something too...

Most of my frequent flier miles are with Delta, so before I whip out that credit card, I head to http://www.skymileshopping.com/ (see my previous post about turning food into miles)

By clicking through this site, for many, many shopping sites I can earn anywhere from 1 to more than 10 skymiles for every $1 I spend at participating sites.  With hundreds (if not thousands) of $$ to be spent, it's another great way to maximize my Skymiles account balance.

Will I buy anything outside of the skymiles shopping site - sure.  But not if I can help it.

What Are The Public Schools Teaching Our Kids?

This evening, we were supporting the Georgetown Elementary School PTA by eating dinner at Chic fil A. If we gave them our little tickets, the school gets 15% of the proceeds of our purchase (and the teacher with the most tickets gets a chicken party of some sort).

As we're finishing up with our meal, and while we are battling Finley to keep her out of the overcrowded play area, Cadence says something that shocks us both.

"Today, at school I learned what an 'ass-kick' is."

As you can imagine, Melissa and I were taken a little by surprise. I asked her to repeat the word several times, with the same result of her saying 'ass-kick' several more times.

Finally, Melissa asked her to explain exactly what as 'ass-kick' is, and Cadence started down a complicated and indirect way of explaining the 'axis' of a sphere...

What are the public schools coming to when your kids don't even learn the correct definition of an 'ass-kick.' Going to have to have a talk with her teacher...

Short Cycle Dispensing Shaping Up

As previously discussed in my post from October 11th, the pharmacy industry that services patients receiving care in what are termed "Long Term Care Facilities" is about to experience a major shake-up.  The Affordable Care Act calls for a very specific change in how pharmacy services are provided to these patients when receiving coverage under Medicare Part D.

The Affordable Care Act (ACA) calls for dispensing of Part D covered medications to residents of these long term care facilities (more commonly known as nursing homes) in 7-day supplies or less, in an attempt to curb costs associated with wasted medications.  The was scored in such a way that this particular provision was expected to generate $6 billion in Part D savings within 10 years.

CMS's proposed rule(s) for changes to Medicare Advantage and Medicare Part D plans for the year 2012 is about to be released (though it may have been held up (purposefully???) waiting for the mid-term election to pass), and here's a preview of some of the highlights related to the 7-day-or-less provision:

• The 7-day-or-less requirement will only apply to Brand Name medications, though Generics are encouraged to be included as well - and CMS indicates they will require Generics at another (future) time
• Products for acute care and those that are "difficult to dispense in 7-day-or-less supplies" are excluded from the requirement (think antibiotics and eye-drops and inhalers)
• CMS will require reporting from plan sponsors (and thus plan sponsors will require reporting from pharmacies servicing LTC facilities) that quantifies "wasted" products.  The rule also requires LTC facilities to return unused medications to the pharmacy for accounting for this purpose (new requirement)
• Part D plan sponsors will basically be required to support all iterations of different 7-day-or-less dispensing techniques, but techniques must be uniform within each facility
• Dispensing methodology must be reported for each LTC pharmacy claim (likely through PDE reporting)
• Copayments will be allowed to be applied on the first transaction of a month, last transaction of a month, or be prorated by days supply, in most cases (pro-rated not allowed on Low Income beneficiaries)
• CMS appears to endorse automated remote dispensing as the most efficient and waste-reducing dispensing technique
• CMS seems to endorse (or at least allow) Plan sponsors negotiating different fees to be paid for transactions dependent upon the dispensing technique used

This is all based on a first read, and is just reflective of a "proposed" rule, which is subject to update and change based upon comments CMS receives.  However, there are some interesting thing here.

Brand Only -

Certain parts of the pharmacy industry have been lobbying for a brand-only exclusion, arguing that added costs of dispensing more often would not be offset by cost savings related to waste on less expensive products.  The proposed $ cutoff being tossed around was $400.  CMS seems to have bitten on this, at least partially, and at least temporarily.  However, CMS will require generics later (I guess they are leveraging the no later than January 1, 2012 implementation requirement in the legislation, at least for generics).

Personally, I see it as difficult for pharmacies and nursing facilities to operationalize brand only 7-day-or-less, and would expect at least some just do it for all meds since they have to do it for some.  There are likely some, however, who will try to implement 7-day-or-less for just the ~20% of scripts that are currently brand.

New Reporting -

CMS has apparently added a new "reporting requirement" for plan sponsors related to unused medications.  This can only be accurately reported by the pharmacies, and for pharmacies to report the amount of unused medications, they have to take it back...  And so, CMS has required that pharmacies take unused medications back and report the amounts to the plan sponsors (who will, in turn, report to CMS).  The idea is apparently for CMS to measure the amount of waste still in the system, AND to correlate the amount of waste with the types of dispensing techniques that allowed the waste to occur. 

This is interesting because they have also inferred that dispensing fees paid to pharmacies (which are most certainly to be renegotiated based upon this change to the industry) can include amounts to pay for processing of returned unused producs (something not common in Part D today, though seems to occur for some state Medicaid programs). 

Facility/Pharmacy Choice on Dispensing Technique -

CMS will require the dispensing technique to be consistent within a particular facility (to meet requirement within the legislation's language around uniformity) but will allow the facility and the pharmacy determine the appropriate dispensing technique for each location.  The plans will simply have to live with and support whatever technique is in place for the facility in which their member resides.

There also appears to be a requirement placed upon plan sponsors to ensure that pharmacies are being uniform within each facility they service, which is new as well.  I hear audit bells...

Dispensing Technique Reported on Each Claim -

I read that CMS will require Part D sponsors to report, at a claim level, the dispensing technique used for each claim.  This can only be reported by the pharmacy, and can only efficiently be accomplished using a field on the claim transaction.  The National Council on Prescription Drug Programs (NCPDP) has been working on an update to the codes available to accomplish this.  (see my previous post about NCPDP and the influence it has in the pharmacy industry)

My question is where this will be reported on the Prescription Drug Record (PDE) submitted by plans to CMS.  I don't believe a field exists today, and so the PDE record layout (which is changing from 2010 to 2011) may need to be updated (again) in order to accomodate this.

Copayment Logic Variability -

An interesting and dissapointing fact is that CMS did not mandate a logic for how to handle copayments.  This lack of direction may lead to confusion in the industry, as plan sponsors appear to be able to choose first fill, last fill, or pro-rate.  I'm not sure, at this point, how pharmacies will know if a copayment has been pro-rated or not.

Automated Remote Dispensing -

CMS all but endorsed automated remote dispensing (currently offered by technology companies like Talyst) as the most efficient dispensing technique in reducing waste in LTC pharmacy services.  This may offer a big opportunity for companies offering this technology, as the current ROI models have really been focused on the Medicare Part A pharmacy segment.  This change, in total, offers remote dispensing technology providers a new market of buyers.

Also of note is the allowance that plans can negotiate different dispensing fees for different dispensing techniques.  This further strenthens the opportunity for these technology suppliers, as pharmacies may be offered higher dispensing fees from plans if they adopt these technologies.  Nothing like a regulatory boost to get your business going.


All in all, I'm still not convinced that the waste budgeted to be saved by this move will be found under the conditions set forth in the proposed rule.  But, it sure will keep the software programmers (and technology suppliers) busy for the next 12 months as the industry grapples with how to be compliant with this new requirement, and how to make it a profitable change.

***

UPDATE 12/11 - Follow-up Post

Veterans Day

Never Forget

"As we express our gratitude, we must never forget that the highest appreciation is not to utter words, but to live by them." -John Fitzgerald Kennedy

"In war, there are no unwounded soldiers." -Jose Narosky

"I think there is one higher office than president and I would call that patriot." -Gary Hart

Cool Travels for a Geocoin

I've previously posted about geocaching.  If you've never heard of it, look at my previous post, or watch the video here.

To demonstrate something cool about geocaching, here is the path that a Geocoin (with a unique code on it that geocachers pick up from caches and later leave in other caches) Melissa and I dropped in Dallas TX has taken since it's initial placement in early October of this year:

Yep, not only has our geocoin gone from Dallas to Alaska, but it took a trip through Hong Kong to get there.  Having never been to Hong Kong myself, I think this is pretty cool.

The goal of this particular coin is to make it to Hawaii.  Interestingly enough, it appears the coin got pretty close (not sure on the flight path obviously) but didn't quite make it yet.  Some coins and other similar geocaching items (like travel bugs) take years to make it to their destination, or never make it at all.  The fact that our coin has traveled more then 13,000 miles since we dropped in 30 days ago is amazing to me.

I think I'm going to go order some more geocoins.  This could be fun!

Ducks in 10-Gallon Hats - Fighting Over Our Money

Members of Congress are getting ready to suit up in their chaps, spurs and ten-gallon hats.  Oh, and don't forget their bills...  duck bills...  lame duck bills.  We're getting ready to watch a lame-duck Congress, dressed for a show-down at the OK Corral, come back into session for a shoot out - the outcome of which will determine all of our tax bills for the near future.

Unless this current Congress acts, the "Bush Tax Cuts" will expire on December 31, 2010.  Democrats are poised to support extending the cuts for those individuals earning less than $200,000 annually and families earning less than $250,000.  The Republicans, alternatively, advocate extending the tax cuts permanently and for all tax filers.

Both parties, by advocating extending tax cuts at all, are agreeing that lower tax bills equate to more money in consumer's pockets, leaving more money for other expenditures, thus driving the economy.  The argument has been, and will continue to be over the costs and benefits of extending the cuts for higher-income individuals.

Here's a great chart showing the possible tax rate outcomes:

From my perspective, what is at odds is the expected value, to the economy, of putting more money (or said otherwise leaving more money) in the pockets of the country's wealthiest citizens.  When taxes are cut for all, obviously the wealthy, like the less wealthy, will spend more as consumers (granted likely on more luxury items) since they have more money in their pockets.  But consumer spending is not the only potential impact of lower taxes if extended to wealthier Americans.  Americans in top tax brackets also own small businesses - lower taxes can mean more reinvestment in business growth, and thus subsequent job growth.  Also, wealthier Americans are more likely to make size able investments to grow their wealth - funds that are valuable capital for companies.  Availability of capital is the key to growth, and just like small business owners, the more money a business has, the more they can spend on growing business - growing jobs.

Alternatively, tax cuts cost the federal government revenue.  Money that doesn't come in through the treasury can't be spent by the government (if you, for a fleeting moment, forget that our country runs huge budget deficits) and if budgets are balanced, reducing tax revenue must come with equal reductions in spending.  It's estimated that the current tax "cuts" (when compared to the alternative rates), if made permanent, would cost the federal government $3.7 TRILLION over 10 years.  That's a lot.  

When people talk about the "cuts" and extending the "cuts" we have to remember that NOT extending the cuts doesn't mean people keep paying the same tax bills, but in fact, tax bills will INCREASE for Americans.  This is an obvious concern for an economy that remains extremely dependent upon consumer spending.  If people's wallets get even slimmer through what amounts to tax increases, the economy is further threatened.

Also of note is the amounts of the $3.7 trillion price tag that is attributable to the wealthy versus those who come in in the lower tax brackets.  $3 trillion of the cost would come from the people the Democrats want to extend tax cuts for.  Only $700 billion comes from the wealthiest Americans.

The best choice on this matter is not clear, and will be fought fiercely in Tombstone D.C.  

Here are the basic options: 

1. Let the tax cuts expire and you threaten the already teetering (though arguably recovering) economy by reducing dollars individuals have available for consumer spending (or heck, to pay their mortgage - let's not forget about the housing market still buried a the bottom of an port-o-potty), and money available for investment or reinvestment in businesses (which drives jobs growth). 
2. Extend the tax cuts for the majority of Americans (raising taxes on the wealthy) and you cost the federal government $3 trillion over ten years, and only really extend the status quo for those who get the cuts.  In this scenario you at least do bring $700 billion into the federal coffers (remarkably close (but still less) to the cost of the last federal stimulus - through spend in a MUCH shorter timeframe - which many argue another stimulus is needed) but federal deficits will continue to rise quickly without any real changes to federal spending.
3. Extend the tax cuts for all Americans, which costs about 25% more that just for the non-wealthy, preserving all consumer spending and current investment rates, but costing the federal government the full expense of the reduced revenue.

Extending the tax cuts is not a fix for the economy, but certainly could hurt the economy greatly if nothing is done and they expire completely.  Alternatively, extending the tax cuts costs us all trillions more in deficits and debt.  The downside of huge debt I'll save for another post...

And so, we're back at the OK Corral.  Boehner and Pelosi are taking up their positions, and pointing their pistols at one another.  I wonder who has the bigger hat?  I just hope neither of them shoots a whole in my wallet...

Michael Jackson's "Desire" and My 7-year Old Daughter

The last time I purchased a Michael Jackson album was in 1992 and I was 13.  I bought the Dangerous album on cassette at a Phar-mor store in Eastgate Ohio.  In the same transaction, I also bought Michael Bolton's Time, Love & Tenderness as well.  These were my two first music purchases, and as you can tell, I was on the edge... or maybe not.

I just about wore out the Dangerous tape, and it was a favorite of mine as I made it (barely) through my teenage years. Not until I found Harry Connick Jr's Blue Light Red Light album, which was given to me by my step-father and was my first CD, did Michael relinquish top spot in my, at the time, limited musical hierarchy.

Fast forward to this year.  Michael Jackson is gone from this earth, and for the first time in 20 years, I own a "new" one of his albums - The Essential Michael Jackson ($12.99 @ Amazon).  Granted, I didn't buy it (my wife Melissa did) but I'm happy to have it, as it offers a nice change from the country music we normally listen to in the car.  I actually like country music, but it's nice to change it up occasionally, and I'm certainly not up on the current pop scene, nor do I really enjoy that style of music these days. 

Something that is wonderful is how much the kids like the Michael Jackson music.  Initially they didn't care for the "newer" music, and wanted us to put the Jackson 5 era stuff on repeat.  But now, they're warming up to even the Dangerous tracks. 

So far, I've really had no concerns about exposing them to Michael Jackson.  He is obviously one of the all-time great musical artists of the 20th century, and I actually want my kids exposed to many different types of music.  I want to wet their musical taste-buds to as many musical styles as possible so they have open minds about music in general later in life.

But tonight, as I drove my oldest daughter (she'll be 7 in December) to her karate class, the song In the Closet came on.  My daughter remarked that she really likes this one, and began to sing along with the chorus.  Innocent enough, right?  There can't be anything damning there, right?  I mean, we long ago cleared the iPod of all music from our youth that contained cursing and language that could be considered risque - anything we really didn't want to have the kids repeating in public.

Here's a portion of the In the Closet lyrics -

One Thing In Life
You Must Understand
The Truth Of Lust
Woman To Man
So Open The Door
And You Will See
There Are No Secrets
Make Your Move
Set Me Free
Pretty tame, except for the word "lust. "

Here's another short section -

Just Open The Door
And You Will See
This Passion Burns
Inside Of Me
Don't Say To Me
You'll Never Tell
Touch Me There
Make The Move
Cast The Spell
Hmmm.  Starting to talk about touching... and passion...

One more little tid-bit -

If You Can Get It
It's Worth A Try
I Really Want It
I Can't Deny
It's Just Desire
I Really Love It
'Cause If It's Aching
You Have To Rub It
Hmmm. Desire.  and aching and rubbing...

See my dilemma?  I mean, I'm really not sure I'm ready (or she's ready) to have any level of conversation about "desire" (at least how it's meant in this song), "aching", "touching" or especially "lust" with my (almost) 7 year old daughter.

Maybe I'm being a prude.  Or, maybe I'm giving her more credit than I should.  It's certainly not hard to argue that she's probably not really thinking about the words, and is more interested in the beat.  But, when will she start listening to the words?  When will she consider what they mean, how they go together, and the story that they tell.  And when will I, out of the blue, get a question from her that I will desperately want to punt to her mother???  I know it's coming...

So, I'll probably not change anything and we'll keep listening to touching, rubbing and aching, even though I'm, inside, scared to death she'll start to piece together that there's some strong emotions in that song.  It's really tame in comparison to some, but she's smart, and she's in school, talking to other kids, and getting smarter and more observant all the time. 

Deep down, I'm just afraid my daughter is still a little young to be hearing about Michael Jackson's "desire" whether its kept in the closet or not. 

If you've got thoughts, advice or guidance, feel free to leave a comment.

Pelosi & Boehner, Like Peas and Carrots, or Carrots and Peas

Following the changing of the guard in the US House or Representatives on Tuesday November 2, there is little question as to the identity of the next Speaker of the House.  John Boehner R-OH has been the House Minority Leader since January 3, 2007, and is expected by most to be selected by Republicans to serve as the next Speaker.

Somewhat surprising is Nancy Pelosi’s decision to run for the position of House Minority Leader following the Democratic rout.  It’s not uncommon for Representatives vacating the Speaker’s seat to stay in Congress, but it was somewhat expected that Pelosi would not run for party leadership following such a slaughter during the mid-term elections under her watch.

The reason for Pelosi’s decision is made clear by a couple statements in her letter announcing her run to other Democrats in the House (11/5):

“We have no intention of allowing our great achievements to be rolled back.”

“…driven by the urgency of protecting health care reform, Wall Street reform, and Social Security and Medicare, I have decided to run.”

Pelosi is making it extremely clear what she intends to do if elected to the House Minority Leader post, (which is not a stretch but also not yet a foregone conclusion).  Considering the fact many of the Democrats who lost their seats in the House were more moderate, this leaves the more liberal base of the Democratic caucus to stay and fight.  Other Democrats in the House will likely easily align with Pelosi philasophically, and will support her strongly.

Republicans have been branded, successfully or not and/or appropriately or not, as the “Party of No.”  My crystal ball is showing a clear change in roles within the House – Democrats will be fighting hard, under Pelosi’s leadership, to protect the “gains” of the Democratic party since Obama’s placement at 1600 Pennsylvania Ave.  There will be a lot of “No” on changes to be proposed by the new Republican majority.

Republicans making plans for the upcoming 2 years were initially quick to rattle sabers and make zealous and likely overstated comments about intentions or plausible impacts.  Even Senate Minority Leader Mitch McConnell got into the act:

"People who supported us - political independents - want it repealed (health care reform bill) and replaced with something else. I think we owe it to them to try." (CBS – Face the Nation 11/7)

But with so much pride and legacy involved from the Democratic side, there is almost no possibility ANY sitting Democrat will go along with a repeal.  So, let’s put that one out of our minds and look to more plausible options.

Boehner’s made some more realistic comments in an interview with FOX News on 11/5:

“This health care bill will ruin the best health care system in the world and it will bankrupt our country. … And secondly, let’s not forget, this is also about jobs.  And if you look at all of the requirements on employers, you can understand why they’re not hiring new employees, because we’ve raised the cost of employment.  … And trust me, I’m going to make sure this health care bill never ever, ever is implemented.”

That sounds like a big promise – but not the one you may have heard before, or the innuendo offered by McConnell.  If you notice, Boehner did not use the word “repeal” but instead made reference to “make sure the health care bill never ever, ever is implemented.”  See my previous post.

The cooperative spirit is likely not going to grace the Capital building anytime soon, and if Boehner and Pelosi are elected to their respective expected leadership positions, we may just see a simple switcheroo.  Boehner will be the one attempting to move forward the business of the American people (or the Republican translation of that business) and Pelosi will be leading the opposition party with questions like “Where are the jobs?”  Because the Republicans’ first order of business will be to attempt to change the course of legislation previously passed under the Pelosi-controlled House, Pelosi will not easily or likely cooperate in any fashion with these efforts, out of pride if nothing else.

So, before we had the two chummy pals in a peas and carrots position.  Now we’ll have carrots and peas.  Same old story, different verse.

B787 - Sky Interior

Beautiful.

A far cry from this:

High-Speed Rail - Coming to America?

“Imagine whisking through towns at speeds over 100 miles an hour, walking only a few steps to public transportation, and ending up just blocks from your destination. Imagine what a great project that would be to rebuild America.” – President Obama announcing a new vision for high-speed and intercity passenger rail service in America (April 16, 2009)

In January 2010, in his first appearance after the State of the Union address, President Obama announced $8B in stimulus funds to support the implementation of high-speed rail in the United States. In May of this year, the US Department of Transportation announced the first payments to States.  In October, another $2.4B was awarded by the USDOT "for planning and construction of intercity passenger rail service."

Some may compare Obama's vision here to those of Eisenhower (the interstate highway system) and John Kennedy (the US space program).  Obama has obviously placed in front of the United States people a BHAG - a Big, Harry, Audacious Goal.  Before we jump in head first out of pride, maybe we should think a bit about the goal itself, and the end-state we seek to reach.

Here's the proposed high-speed rail plan:

Interesting to me is the fact that these "corridors" have been in development and planned since starting in 1991.  For the history of the high speed corridors, click here.

Personally, what I see in the map above is a series of discrete and separate rail systems that do not fully interconnect.  The viability of these rail systems to act as an alternative transportation method for Americans looks extremely limited.  Not only are only a small portion of the country's cities served by the system above, the connectivity between them is missing as well. 

Compare the above to the availability of commercial air travel (image below), and you can see how served locations (rail) will be extremely few relative to locations served by air. 

Several changes in state government could drastically impact the administration's plan around high-speed rail.  Leaders in Ohio, Wisconsin and Florida have all either already made strong statements about the fact that they do not support the President's high-speed rail plans (and will not take federal funds), or have at least questioned the wisdom of moving forward.  Other states (like New York) stand ready to accept their funds, should they refuse them.

Something to consider as well is that the funds coming from the federal government do not cover the total expense required to put these systems in place, so hundreds of millions, if not billions of dollars will need to be invested by state and local governments in order to get these things done.  With most states already in financial crisis mode, it seems unlikely states will be able to come up with the money.

I did a little math, and I estimate the time involved in traveling from our home in the Louisville area to visit our family in Cincinnati (connected on the rail map above through Indianapolis) would take at least 2.5 hours on the high-speed train lines, including an assumed 30 minute connection.  That estimate doesn't include local public transport (bus) to/from the train stations and our initial starting point and final destination.  Driving time would be approximately the same (2.5 hours). 

I also did some basic cost comparisons.  Obviously, since this system doesn't exist yet, fares cannot be predicted.  However, I estimated cost for our family to travel this route as being the same as a Greyhound bus trip.  At $240 round trip for our family of 5, it is obviously more than the $50-60 in gasoline we would spend driving our own vehicle direct.

So, high speed rail would likely save no time and likely cost more than driving ourselves (gas for our own vehicle, versus ticket cost, even at Greyhound equivalent fares) to our most common destination. 

US high-speed rail may come to pass, but until it is fully interconnected, much more developed and mature than the current map/plan, and offered at a reasonable cost that makes it less expensive than both personal vehicle and commercial airfare, it will have limited viability as a true alternative mode of transportation.  I understand the sexy appeal (though likely a novelty for most) of whisking across the countryside on rails, but with less convenience (than air travel) and more cost (than driving a personal vehicle), it certainly doesn't seem it will challenge existing travel infrastructures anytime in the next several decades, or even in my lifetime.

An Invisible Force In Pharmacy - NCPDP

If you've ever walked into a pharmacy, used a prescription drug coverage, and walked out a short time later, paying only your copayment, you've been impacted by a small but powerfully influential industry group by the name of NCPDP.

The National Council for Prescription Drug Programs (NCPDP) is a standards organization that quietly has shaped much of the patient experience at pharmacies across the US.  How does your pharmacy know for sure you have prescription insurance coverage when you walk in? How do they know your copayment, or how much they will be paid? If it's your first time visiting a particular pharmacy, how can the pharmacist be alerted to potential drug interactions with drugs you've filled elsewhere?

The answer to all of the above questions is, at least in part, NCPDP. 

NCPDP is a voluntary organization comprised of members from pharmacy providers (CVS, Walgreens, etc), pharmacy payers (health plans and pharmacy benefit managers (PBMs)), software vendors who provide management software to stakeholders in the industry, and anyone else interested in participating.

Through controlled procedures that ensure order and prevent even the appearance of any illegal or improper activity between competitive entities, NCPDP brings together perspectives and opinions from all across the pharmacy industry. Normally somewhat adversarial competitors and trading partners (people paying the bill and people being paid) come together to develop and implement standards for operating in the pharmacy space. The altruistic goal of the organization is to standardize pharmacy-related business processes between trading partners in order to bring efficiency and benefit to all involved.

In most industries, absent governmental mandates, standards are generally voluntary, and only fully embraced when there is a benefit to all involved. With somewhere around 80,000 pharmacies in the US today and hundreds (if not thousands) of payers, it would be improbable that, without an industry standard for telecommunication between these partners, efficient or even effective communication could occur.  For this reason, the vast majority of pharmacies and payers have, over time, voluntarily adopted the NCPDP standards.

The Health Insurance Portability and Accountability Act (HIPAA) brought any straggler into line. Basically, HIPAA governs the controls and protections for health information. Since transactions to share information regarding prescriptions involve, unavoidably, personal health information, HIPAA would understandably be concerned about pharmacy transactions. For that reason, HIPAA recognized the NCPDP telecommunications standard as approved under HIPAA. 

Recognition under HIPAA gives the industry-based standard a unique position, in that it has binding power under law.  The standard is, in effect, no longer voluntary.  In addition, the Centers for Medicare & Medicaid Services (CMS), who greatly increased their presence in  the pharmacy market in 2006 through the Medicare Part D benefit, has also begun to use the NCPDP workgroups as a sounding ground for new ideas, and to gain industry perspective on the limitation, benefits and impacts of new policies being considered.

Through the years, NCPDP has steadily increased in reach and influence, and now represents one of the premier cross-functional industry-wide groups of individuals impacting pharmacy today. Those who want to understand the reasons for or driving forces behind  pharmacy industry changes, or the solutions being considered, argued and implemented to address industry issues and needs should watch NCPDP closely, study their activities, and get involved. Anyone can participate, and all are welcome. The best thing that can happen in such an industry organization is the infusion of new participants with new ideas.

Next time you visit your drugstore and get your prescription filled, know that NCPDP made the experience (whether good or bad) possible, and continues to work to improve the way the pharmacy industry goes about the important business of taking care of patients.

www.ncpdp.org for more information