A last-minute change slipped into the Senate Finance Committee bill will exact huge payments from families subsidized to buy health care coverage through the insurance exchanges set up by the bill, the Congressional Budget Office report said.

Deemed the "fail-safe" mechanism, the CBO estimated the subsidies earmarked for families earning between 100 and 400 percent of poverty will be reduced by 15 percent. Since the CBO analysis estimated about 22 million working poor families would receive $68 to $98 billion a year in subsidies between 2015 and 2018 when the requirement that they buy mandatory coverage through the exchanges goes into full effect, each family would pay on average $600 more a year in out-of-pocket costs.

"This provision just makes the subsidies a joke," one consumer advocate complained late Thursday. "It was a last minute change added to make somebody happy."

The fail-safe mechanism is linked to another little noticed provision in the bill: it mandates that health care costs rise at no more than the gross domestic product plus one percentage point, also starting in 2015. A newly empowered Medicare payments commission would recommend to changes in Medicare coverage to meet that standard unless Congress voted down its recommendations.

Estimating the budget impact of these variables was impossible, the CBO analysis sent to Capitol Hill late Wednesday noted. It also made it impossible to include an estimate of the increased charges from the fail-safe mechanism in its budget calculations.

But in a letter sent to Finance Committee chairman Max Baucus (D-Mont.), CBO chief Doug Elmendorf noted that "if the mechanism was implemented to reduce exchange subsidy rates in some years, it would probably result in significant reductions to the dollar volume of such subsidies and associated reductions in coverage." He then estimated those reductions would equal about 15 percent of the total subsidy package between 2015 and 2018.

Five years ago, I conducted a study that showed about one in eleven authors of articles in major medical and scientific journals failed to disclose conflicts of interest as required by the journals' author guidelines. The Journal of the American Medical Association had the highest rate, where about 11 percent failed to disclose. The New England Journal of Medicine had the lowest non-disclosure rate at about 5 percent.

Today, NEJM published a study that compared the disclosures generated by court settlements with five hip and knee device manufacturers to disclosures made at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons. About 3 in 10 failed to disclose those conflicts. In a follow-up survey, about 4 in 10 surgeons who failed to disclose said they didn't think the payments were relevant to the topic they were discussing at the meeting.

For those steeped in the arcana of conflict-of-interest disclosure rules, the relevance test is one of the major bones of contention. If you consult for Pfizer, and talk about a drug from AstraZeneca, should you disclose your consulting gig? "Of course" is the easy answer since the companies compete on a wide range of products. But what if your consultancy is on a rare disease in which AstraZeneca has no product or development program?

Those Talmudic distinctions offer an easy out for physicians on the payroll of drug and device firms, allowing them to hide some of their financial ties from editors at major journals and federal officials screening nominees for advisory committees. Their internal gavel comes down: not relevant, no disclosure required.

The beauty of the court settlements in the device cases, as well as the Physician Payments Sunshine Act in the health care reform bills, is that they ignore the fine distinctions and opt for universal disclosure. But as this new study points out, even in the wake of having an easily accessible database, physicians will find reasons to avoid making those disclosures in public fora, whether in a printed article or before making a speech to an annual convention.

Is "relevance" relevant? In my view, it's just a convenient excuse for not baring all and letting the reader/listener/reviewer decide. It's time to get rid of the relevance dodge.

A tax on so-called Cadillac plans will miss the mark, argues a new briefing paper from an insurance actuary at Milliman, a leading corporate benefits consulting firm. Why? "The high cost of these plans has as much to do with the characteristics of the covered population as it does with benefit richness," the study says.

Hat tip to Robert Laszewski and his excellent blog for pointing this study out. (I know, I know. These guys are all industry consultants. But they do get things right every once in a while, especially on this issue, which i've written about here, here and here.) 

The morning papers are filled with relevant health reform stories, but two stand out. They weren't reported by journalists, but were experience-based opinion pieces offered by people on the front lines of delivering and insuring health care.

The first comes from the Washington Post, where a family practice physician reports on the battery of tests he received after checking into the local emergency room for excruciating eye pain while on vacation. Despite an ultimately accurate self-diagnosis of shingles, he submits to his physicians' orders for an ever escalating battery of tests. My takeaway lesson from his story is that if a skilled physician cannot resist orders for expensive tests and unnecessary drugs, there is no chance that individual consumers, even if they have more skin in the game, will be more successful. 

The second story comes from an op-ed in the New York Times, where a Texas regulator, who served on that state's ill-fated attempt in the 1990s to set up an insurance exchange for small businesses, concludes either a strong public plan or very tight regulations are needed to make exchanges work. Otherwise, he states, insurance companies will cherry pick the insurance pool and doom those with high-cost employees and family members to unaffordable plans.

It's telling that I found those stories much more compelling than the best journalism in today's papers. There was a solid Post story about how the U.S. lags in preventing deaths that could be prevented through health care interventions. There was also a Times take out on insurance exchanges, which included a brief sidebar on a Utah exchange aimed at small businesses that sounds suspiciously like the failed Texas model.

It's not that the good reporters who wrote those stories couldn't deliver powerful pieces. But the sad truth is that quick turnaround stories based on studies, or overviews based on numerous telephone calls to policy wonks, the thin gruel now offered by ever-shrinking newsrooms, will never have the power of well-reported, anecdote-driven stories that can only be produced by reporters spending serious time on the ground with real people and practitioners.