I have to complement our Congressional leadership for its political fortitude and wisdom in preparing 2010 health reform legislation which is well suited to the 1970s and 80s. The late Richard Nixon, who brought us HMOs in a serious effort at health care reform (which became fouly mutated under the counter-evolutionary pressures of insurers, hospitals and other providers) would have been proud to see the 2010 reform just before "le affaire Watergate"cut his presidential career and his interest in American health care short.
What is being trumpeted as health reform is more of the old health system, redressed and reworked, with the old guard in control. The program has been shaped by pharmaceutical companies, insurers, chambers of commerce, hospital associations, device manufacturers, health care unions, high-roller physicians and other providers, through their lobbyist minions to be certain that their controlling interests and their profit centers are not perturbed, their stock prices ever climbing, their executive salaries not diminished, and the care, which Americans will receive, not improved.
[Remember: a pharmaceutical (and other company which makes its money in health care) profits by selling drugs over a long time for a chronic disease, not by efficiently curing a disease early in its course. An insurer makes money by keeping your doctor on the phone for 45 minutes, hoping that she will hang-up the phone, rather than promptly authorizing the care you need.]
How are we going to staff the clinics and hospitals to provide the facilities and office visits that adding more than 30 million Americans to the insured list will demand ("the doctor is completely booked for the next ten weeks, but we have one appointment 71 days out with our new physician's assistant")? Will the legislation's effect on doctors' offices cause them to look like overcrowded hospital emergency rooms where only visibly dying patients get immediate attention?
Under the 2010 health reform proposal, where are the skills neeeded to diagnose and treat cancers, degenerative diseases, trauma and neurologic disorders in our aging population to be gained?
Where are the financial incentives which will drive our younger generation to acquire an interest, skill and understanding of chemistry, math, physics, biology and the other sciences which will provide the springboard to careers in the healing professions? Is our "health reform" simply training generalist doctors to take care of sore throats, blood pressure elevations and type 2 diabetes using duplicative drugs purveyed by pharmaceutical companies? Will the recruitment and education of coming generations prepare them to understand complex scientific concepts of statistics, DNA, genetics, epigenetics and their interrelationship with disease and health or is there concern among political and industrial leadership that a bright, well-trained and informed health care leadership will be too hard to control?
In a country which prides itself on its capitalist tradition, the proposed 2010 health reform incorporates few capitalist incentives to recruit the people and brains who we will need to make the system work and few capitalist incentives to improve the quality of care available to Americans. It rewards the same individuals, interests, companies, systems and institutions which have traditionally lined up at the trough for slop.
It's perverse. The Republicans are less capitalist than the Democrats, the the conservative Democrats are less capitalist than the Republicans. Go figure!
Showing posts with label Reform. Show all posts
Showing posts with label Reform. Show all posts
Tuesday, December 29, 2009
Tuesday, October 27, 2009
The End Game
In chess, beginners can start the game with a flourish, but they lose. Average players can work into the middle-game with some wins and some losses. But the champion chess player excels in the end game where inventiveness, visualization, skill and guts make the difference between winning and losing.
Health care reform is approaching the end game. The issue is whether Reid, Pelosi and Obama have the inventiveness, ability to visualize, skill and guts to win true health care reform with a federal alternative insurance program. Are the lobbyists for pharmaceuticals, insurers and health professionals going to determine how and whether Americans get the health care they need and the nation can afford? Are there any legislators who think in terms of what is best for America and its citizens rather than their political supporters?
Will Obama, Reid and Pelosi be check-mated?
Health care reform is approaching the end game. The issue is whether Reid, Pelosi and Obama have the inventiveness, ability to visualize, skill and guts to win true health care reform with a federal alternative insurance program. Are the lobbyists for pharmaceuticals, insurers and health professionals going to determine how and whether Americans get the health care they need and the nation can afford? Are there any legislators who think in terms of what is best for America and its citizens rather than their political supporters?
Will Obama, Reid and Pelosi be check-mated?
Tuesday, July 21, 2009
Our Health System - A Zero Sum Game?
"Utilitarian Philosopher" Peter Singer, who wrote "Why We Must Ration Health Care" in The New York Times Magazine, July 19, 2009 approaches several health care ethical issues. He starts with a traditional economist's view, observing that health care, a scarce resource, is to be rationed. Moving through examples of structured (i.e., Britain), unstructured (the American uninsured), and structured but not acknowledged publicly (American government), existing rationing systems, he notes several ethical issues inherent in each of these systems and suggests approaches to resolution.
Underlying Singer's observations is, what I interpret as, his belief that health care is a zero sum game. Reminiscent of Senator Ted Kennedy's 1960's physician payment proposals, a budget basket is established: those who qualify for allocation priorities leave less less for later claimants. As I have argued in many blogs, payment to insurers for 25% administrative overhead claims leaves significantly less in their treasuries to actually buy health care services and products.
But, as Singer recognizes, the problem is defensibly defining who is worthy, not in the Saturday-Night-Live sense, but in the sense of identifying humanitarian and socially beneficial criteria for worthiness. He and we run into the application of population statistics to individuals who may be cut-off from palliative or curative treatment because population statistics indicate that they will not live long enough, or well-enough, to justify spending scarce resources on them and thus depriving more "worthy" people of care. This is another form of rationing.
In my practice of hematology, I learned that I could not predict who would live and who would die, who would have lives incorporating many good days, and who would have lives focused on suffering. I could not tell whether my patient, riddled with cancer, would outlive his young wife who brought him to my office (he did). I could not predict that the sixteen year old would receive a remarkable new experimental treatment called kidney transplantation, and outlive many who had more mundane and less threatening illnesses. In short, I could not apply population statistics to my patients and I believe that health reform based upon the principle of such application is fraught with hazard and stinks of charlatanism. I worry that the zero sum game philosophy will yield tragic results.
If you want to know what Singer proposes, read his Times article. Your time will be well-spent.
Underlying Singer's observations is, what I interpret as, his belief that health care is a zero sum game. Reminiscent of Senator Ted Kennedy's 1960's physician payment proposals, a budget basket is established: those who qualify for allocation priorities leave less less for later claimants. As I have argued in many blogs, payment to insurers for 25% administrative overhead claims leaves significantly less in their treasuries to actually buy health care services and products.
But, as Singer recognizes, the problem is defensibly defining who is worthy, not in the Saturday-Night-Live sense, but in the sense of identifying humanitarian and socially beneficial criteria for worthiness. He and we run into the application of population statistics to individuals who may be cut-off from palliative or curative treatment because population statistics indicate that they will not live long enough, or well-enough, to justify spending scarce resources on them and thus depriving more "worthy" people of care. This is another form of rationing.
In my practice of hematology, I learned that I could not predict who would live and who would die, who would have lives incorporating many good days, and who would have lives focused on suffering. I could not tell whether my patient, riddled with cancer, would outlive his young wife who brought him to my office (he did). I could not predict that the sixteen year old would receive a remarkable new experimental treatment called kidney transplantation, and outlive many who had more mundane and less threatening illnesses. In short, I could not apply population statistics to my patients and I believe that health reform based upon the principle of such application is fraught with hazard and stinks of charlatanism. I worry that the zero sum game philosophy will yield tragic results.
If you want to know what Singer proposes, read his Times article. Your time will be well-spent.
Tuesday, June 30, 2009
Framing The Health Care Reform Debate
When carpenters frame a new building's walls, the building takes a recognizable shape. Passers-by get a sense of structure, a release of anxiety, the assurance that the process is reasonable and guided by established principles of physics, mechanics, truth and responsibility.
Unfortunately for his investors, Bernard Madoff's framing process provided his investors with a sense of structure, freedom from anxiety, and assurance - echoed by respected financial experts - that his structure was reasonable, in accordance with the principles of the financial industry of which he was an noted executive, responsible and truthful. A Ponzi scheme is an exercise in framing for deceit.
Framing is not restricted to buildings and financial structures: it is also part of our daily political exposure. Arguments are carefully framed and discussed by health care "experts" representing entrenched vested personal and business financial interests in advocating or opposing health care reform. We hear the expert-of-the day on television proclaiming that he or she has a solution or a reason not to solve, our health care problems and we hear our Congresspeople in high dudgeon about the foolishness of some of the proposals.
What does the "frame" look like? How does it compare to the truth?
The Norman Rockwell painting showing a doctor by the bedside, indelibly etched into our psyche, is a good place to start. It is part of the mythology of American medicine: each person should have his or her own honest and competent personal physician who is completely dedicated to him or her, and can marshall all necessary care without any intervention by an outside force. Unfortunately, the physician that one sees when really sick is not likely to be the physician who might know you; the hospitalist may never have met you before admitting you to the hospital and probably will not know you after discharge. The specialists who undertake your care come and go, often unfamiliar faces appearing at odd hours. Medicine has changed from Rockwell's days when the doctor sat by the bedside, waiting for the patient to die because the doctor had no antibiotics, little technology, and scientific knowledge which was woefully deficient. And today's family practice physicians have the impossible task of being knowledgeable in many complex fields requiring their attention today.
Another myth grew from the non-profit operation of early health insurers such as Blue Cross and Blue Shield and non-profit HMOs, the latter established in response to Richard Nixon's actions supporting a new system of care. Insurers and HMOs have perpetuated an image of providing service and valuable expertise to health care, rather than acknowledging that they are essentially system integrators which primarily contract with networks of providers and themselves provide little or no health care, but lots of resource-draining bureaucratic intervention and political contributions.
Another frame issue is the concept that, as scientifically and technologically advanced Americans, we now provide high-quality and efficient health care to all who need it and that health care reform will exponentially increase health care expense. This is a dubious position: overflowing hospital emergency departments (many roadblocked by the uninsured) are many times more expensive than a doctor's office for providing episodic non-critical care. With health reform, why shouldn't we develop money and life-saving efficiency rather than perpetuating the wasteful system that perpetuates income flow to selected self-serving segments of the health care industry and poor quality inefficient care to many Americans?
Unfortunately for his investors, Bernard Madoff's framing process provided his investors with a sense of structure, freedom from anxiety, and assurance - echoed by respected financial experts - that his structure was reasonable, in accordance with the principles of the financial industry of which he was an noted executive, responsible and truthful. A Ponzi scheme is an exercise in framing for deceit.
Framing is not restricted to buildings and financial structures: it is also part of our daily political exposure. Arguments are carefully framed and discussed by health care "experts" representing entrenched vested personal and business financial interests in advocating or opposing health care reform. We hear the expert-of-the day on television proclaiming that he or she has a solution or a reason not to solve, our health care problems and we hear our Congresspeople in high dudgeon about the foolishness of some of the proposals.
What does the "frame" look like? How does it compare to the truth?
The Norman Rockwell painting showing a doctor by the bedside, indelibly etched into our psyche, is a good place to start. It is part of the mythology of American medicine: each person should have his or her own honest and competent personal physician who is completely dedicated to him or her, and can marshall all necessary care without any intervention by an outside force. Unfortunately, the physician that one sees when really sick is not likely to be the physician who might know you; the hospitalist may never have met you before admitting you to the hospital and probably will not know you after discharge. The specialists who undertake your care come and go, often unfamiliar faces appearing at odd hours. Medicine has changed from Rockwell's days when the doctor sat by the bedside, waiting for the patient to die because the doctor had no antibiotics, little technology, and scientific knowledge which was woefully deficient. And today's family practice physicians have the impossible task of being knowledgeable in many complex fields requiring their attention today.
Another myth grew from the non-profit operation of early health insurers such as Blue Cross and Blue Shield and non-profit HMOs, the latter established in response to Richard Nixon's actions supporting a new system of care. Insurers and HMOs have perpetuated an image of providing service and valuable expertise to health care, rather than acknowledging that they are essentially system integrators which primarily contract with networks of providers and themselves provide little or no health care, but lots of resource-draining bureaucratic intervention and political contributions.
Another frame issue is the concept that, as scientifically and technologically advanced Americans, we now provide high-quality and efficient health care to all who need it and that health care reform will exponentially increase health care expense. This is a dubious position: overflowing hospital emergency departments (many roadblocked by the uninsured) are many times more expensive than a doctor's office for providing episodic non-critical care. With health reform, why shouldn't we develop money and life-saving efficiency rather than perpetuating the wasteful system that perpetuates income flow to selected self-serving segments of the health care industry and poor quality inefficient care to many Americans?
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