Health care: The professionals speak
September 9, 2009Jon Brooks Comments Off
Tomorrow we’ll be covering reaction to Obama’s big speech, but for today we thought it would be interesting to take a look at some of the many blogs addressing health care reform. While the town-hall clashes have driven a lot of the media coverage and informed the debate to perhaps an outsize degree, medical professionals have been hashing out these issues online for a long time. A digest of some of the more interesting recent posts:
From DB’s Medical Rants:
Making rounds this morning, we went to see a patient who had a stent placed yesterday. I sat down to discuss the implications of a diagnosis of coronary artery disease. I started with the statement that she would be talking 4 drug classes – aspirin, ACE inhibitor, beta blocker and statins. As I finished she turned to me teary eyed and asked if she would be able to get her drugs for $4 at WalMart (or other similar store). When I said yes, she smiled and cried.
I wish I had a video to place on YouTube. The entire team had the same reaction. We took a situation that had her worried about money, and because of low cost generics she had great relief. We felt great that money would not interfere with her secondary prevention.
We know that secondary prevention helps and decreases subsequent hospitalizations. I know that those who want the status quo label a public option as government run health care. I still favor (with important caveats) creating a public option for the patients who fall between the cracks. While some will not take advantage of a public option (like many patients do not take advantage of the VA benefit), many will. We have poor citizens who cannot afford basic health care. We should develop a reasonable way to help them avoid the emergency department and hospitalization. I think it makes economic sense.
From The Sentinel Effect:
There’s no point just blaming Max Baucus, Rahm Emanuel, or Barack Obama for the current unpleasant state of health reform – although they’ve each earned their share of criticism. The Left bears some responsibility, too, for failing to set the stage for meaningful change. By granting too much authority to “experts” and ceding their judgment to the resulting groupthink, many progressives laid the groundwork for the poor state of health reform today.
The public option’s in trouble. And if Max Baucus and the other centrist Dems have their way Americans will be forced to buy health insurance that costs $12-14,000 per year. Progressives are finally raising a hue and cry about this burden, but a year ago they were busy promoting the idea that mandates were the centerpiece to meaningful health reform. Now, as the reality of this “reform” takes shape, it’s becoming clear how badly this could turn out. Rational options are being proposed. But with the mandate issue all but resolved politically, progressives have no leverage left to push their agenda…
It was clear long ago that any plan that imposes them on the American public without first creating significant savings would be a disaster, both politically and in human terms. As things stand now, a family of four without employer coverage trying to get by on $75,000 could suddenly be forced to fork over 20% of their income to a health insurer – or face government punishment…No! “Mandatory universal health insurance” is not a progressive position…
From Disease Management Care Blog:
Passage of the Social Security Act of 1965 , the Civil Rights Act and other important social legislation demonstrated our collective ability to achieve new heights for modern America. Yet, something derailed Washington DC’s momentum. What was started by the Great Society was slowed by the Reagan Revolution and reached its limits when Clinton’s health reform failed…
An alternative world view is growing in our collective consciousness. It prefers networked over hardwired, parallel over serial, organic over static, tailored over pre-fab and synergy over reductionism. Its currency is communication, its actions are individually informed and the outcomes are fractal. It resists established business models and it certainly isn’t taxable. It’s face is YouTube, Blogging, Twittering, cloud computing and chaos theory while its symptoms are outsourcing, open sourcing, and multi-tasking. It can be easily mistaken for naivete, libertarianism, survivalism and conservatism. It’s a wild card in our body politic; how else could Ron Paul become so….. cool? What else explains the misinterpretation of Federal payment for living wills as ‘death panels?’ It’s not the ‘web’ and our ‘Communication Age’ only partially explains it. It’s ….synaptic.
It is being underestimated by and hasn’t helped those in favor of health reform. It has aided but hasn’t been harnessed by reform opponents. Its cultural sexiness has greater appeal than the efficiencies from central command and control and its ascendancy is eclipsing classic liberal notions of social justice and progressivism. Government may be able to preside but it cannot own this. It is too complex, nimble and amorphous.
It’s a mistake to think of health care as a right. It is not a right; it is a good. Freedom of speech, by contrast, is a right, as is freedom of religious belief… Health care is different. It is more akin to the other goods which sustain life: food, clothing, and shelter. A well-ordered society exists to protect its members from the unlawful taking of life, and is structured to facilitate its members’ acquisition of these goods.
But health care differs from these other goods: First, health care is not absolutely essential for all people on a daily basis; second, there is an insufficient supply in this world to meet the demand of those who would have it. There is enough food in the world to feed everyone. Hunger and famine are the result of its inadequate distribution, not its absolute dearth… Health care, in contrast, is a far scarcer resource…
Rationing must occur, but it need not be admitted. Denying the truth of rationing is more common in government-run health care schemes than private ones, because the government is reluctant to have the people know this ugly fact. Government-run programs, therefore, are more likely to disguise the rationing. This plausibly deniable form of limiting health care is called implicit healthcare rationing, and it assumes many forms. Rationing by termination occurs when patients are discharged from the hospital earlier than is medically optimal. Rationing by dilution occurs when second-best rather than first-best treatment is provided. Rationing by rejection or redirection involves healthcare providers turning away patients whose care will be inadequately reimbursed. This is commonly seen now in the Medicare and Medicaid programs, because those programs reimburse providers at a rate substantially lower than private insurance plans. Perhaps more common than those forms of rationing is rationing by delay, as exemplified by the outrageous amount of time patients in Canada must wait for hip replacement surgery or colonoscopy. The unifying theme in all these forms of implicit rationing is that, without admitting it, they force some patients to forego medical care that they want and are ostensibly entitled to receive.
Private insurance plans sometimes include an element of implicit rationing, but because they are, at heart, contractual agreements between the insurance company and the insured are more likely to ration health care explicitly. The many pages of the healthcare plan describe what is a covered service, which providers will be reimbursed for services, the duration of coverage, the dollar limit, and so on. The advantage of explicit over implicit rationing is obvious: It gives potential customers of the insurance plan information to use when deciding which insurance plan to buy, and gives them clear expectations of services to be delivered. Implicit rationing, by contrast, may have the sweetness of a promise, but is usually succeeded by the bitterness of a promise broken.
All modern societies ration health care. A wise society considers the options and chooses a method of doing so which best conforms to its values and capabilities…
From Managed Care Matters:
Obama’s health reform speech – what to watch for:
The reactions of Sens Grassley, Enzi, and Snowe are more important than the content. More important, even, than any Presidential pronouncements about public options and tort reform. Without bipartisan support, however thin, nothing gets done, and these are the three keys to that elusive bipartisan stamp.
Cost control – to date the Dems in the House have passed several bills out of Committee greatly expanding coverage at huge cost. Health reform without cost control is not possible nor should it be. The President must address cost, and do so directly.
Lines in the sand – I don’t expect there will be any, especially any referring to a public plan option from day one. But there will be ‘requirements’ for coverage, perhaps timeframes, and possibly a trigger for implementing a public option if specific criteria aren’t met by the private insurance market. How tight these are will go a long way to revealing how far the President will go to get reform passed.
Tort reform – the President’s treatment of this topic will be highly instructive. If he signals a willingness to include tort reform in a health reform bill, that will show a) he’s open to make big concessions to get reform done; and b) opponents that the stakes are raised. Getting tort reform done is a high priority for many in the industry, and they will likely be willing to compromise on other points if they get what they perceive to be meaningful reform.
What to ignore
The slamming by opponents and hyperbowling (a term used to describe advocates hurling positive adjectives at any microphone) immediately after the speech. Turn off the coverage and get back to your fantasy football picks – it will be more productive and less stressful.
From Health Care Policy and Marketplace Review:
The time could be right for centrist Republicans to pragmatically wrap their heads around this issue. After all, the approaches that are known to drive down costs and improve quality can easily be embraced by true conservatives who clamor for market-based solutions. Now, out of power and longing to demonstrate that they can produce substantive answers to our problems, the challenge will be to turn against their traditional industry benefactors and act on behalf of the American people.
Four major areas of health care change that should come easily to centrist Republicans.
• Bulletproof Health Care Security. This is the idea that everyone would have significantly improved access to care, that the employer-sponsored system would remain available for those who like it, and that Congress would be required to use the same system that they pass for the rest of us.
• Medical Malpractice Reform. The Republicans have the Democrats where they want them on this one. There is no good reason why our current Med Mal system, as capricious and ineffectual as it has been, has not been revised with expert systems, except that the trial lawyers, in exchange for hefty financial support, have received protection from the Democrats. It’s time to fix this problem that pervades our health care provider community.
• Paying for It. This is acknowledging that subsidies will be required for those who can’t afford health care at its current cost level, and that there are ways to structure the new cost that are more sensible…the nearly forgotten Wyden-Bennett bill would be cost neutral in its second year.
• Tough Cost Containment. As we said above, this has been the Congressional Democrats’ proposals’ most glaring and conflicted flaw. It is an area that, with a focus on primary care, paying for results instead of piecework, and cost/quality transparency, could dramatically drive down cost while improving quality, rightsizing our health system and going a long way toward ameliorating the most pernicious drag on our larger economy
Collaborating with Democrats or, failing that, taking the lead to demand well-understood cost control mechanisms, would send a clear message that some Republicans are actually interested in problem-solving, not simply nay-saying.
From InsureBlog
Roughly 85% of the population has health insurance and everyone has access to health care…. Most people pay something for health insurance and health care, but about 25% of the population is covered by Medicare and Medicaid and pay little or nothing for their coverage. The cost of health care to them is significantly discounted.
When Washington tried to expand the housing market by making mortgages available to almost everyone they interfered with free market forces and the result is the mess we have now.
The same thing will happen if they interfere with health care, but what they are attempting to do is even worse than what they did to the mortgage market.
They wanted to make mortgages available to 30% of the population but without unraveling what was working for the other 70%. Of course along the way some folks who already had a home mortgage decided to jump on the wagon and refinanced their homes up to and sometimes even exceeding the fair market value.
Washington wants to make health insurance available to everyone but in doing so, they want to completely unravel a system that is working for 85% of us and make health insurance more expensive for everyone.
From the Healthcare Economist:
Americans pay more for medical care than any other country and have one of the highest levels of income per capita of any country in the world. Despite its immense wealth and healthcare spending, the United States ranks 50th in life expectancy, worse than Jordan, South Korea, and Bosnia and Herzegovina. In a Commonwealth Fund report, the U.S. ranks last among 19 countries according to the criteria of “Mortality amenable to medical care.”
Despite these facts Preston and Ho (2009) claim that the American medical system is in fact very good. Instead of using overall life expectancy, Preston and Ho use more accurate measures of how well the American health care system operates. One could use the incidence rate of disease. However, effective diagnosis and early diagnosis will inflate statistics measuring incidence–since early stage disease is found in more patients–but also increases the probability a treatment is successful. For instance, “the United States has a higher prevalence than Europe of the major adult diseases, including cancer, heart disease, and diabetes (Thorpe et al. 2007; Avendano et al. 2009). But higher prevalence could reflect higher incidence, better detection, or longer survival resulting from more successful treatment…Relatively high survival rates imply either that the disease has been detected unusually early or that treatment is unusually successful.”
The thesis of the paper is that the U.S. does a better job of screening patients for cancer as well as providing more aggressive treatment…This still leaves the question of why life expectancy is so low when the U.S. health care system is good. Likely the reasons are behavioral (e.g., smoking, obesity, stress) or public health related (e.g., clean drinking water, sanitation, pollution), and are not due to problems within the medical system. While the U.S. health care system is far from perfect, it is likely comparable or slightly superior to the medical care received in other developed countries.
