If you haven't seen the NY Times Sunday (6/12/09 p. 7) editorial "Doctors and the Cost of Care," you should check it out. It focuses on a report by Harvard-affiliated Dr. Atul Gawande who concluded, after investigating high Medicare health care costs in McAllan Texas (population-141,000 with 103 physicians per 100,000 which is less than the U.S. average), that doctors' over-treatment of patients was responsible. Citing Dartmouth Research, the editorial echos the opinion that " . . . more costly areas and institutions provide a lot more tests, services and intensive hospital-based care than the lower cost centers . . . . yet their patients fare no better and often fare worse because they suffer from the over-treatment."
Numbers? Where are the numbers? Whose doctor is it that is testing too much and over-treating? Is the indictment applicable to 2 percent of the physician population, 98% of the physician population, or 50 percent of the physician population. Are these doctors practicing outside the standard of practice for their specialties (these days, even family practice is a specialty)? If they are, the solution is medical board investigation and disciplinary action, medical staff investigation and disciplinary action at the local level, and (unfortunately) appropriate lawsuits for poor practice conduct resulting in injury. But if these physicians are practicing within the standard of practice one must ask, what is the problem? Or is there a problem?
Yes, there is a problem. In part, it is in the education system that provides basic medical education and continuing medical education which is often influenced by pharmaceutical and medical device companies (through their detail personnel, hired-hand expert speakers, subsidized medical journal articles). There is also a problem with direct-to-patient advertising which is focused on having the patient demand the sponsor's product on his or her next visit to the doctor's office or even the urgent care clinic or emergency room. Pharmaceutical companies and device manufacturers, and in some cases universities trying to corner the medical market, set a "standard of medical practice" which is profitable for them and implicitly threatens those doctors who don't prescribe their products as "practicing outside the professional standard" which these companies have conned physicians and the public into believing is appropriate.
It also involves the marketing departments at HMOs, which measure health care quality in terms of "patient satisfaction" which is an entirely different concept. Under the marketing perspective, if a patient is disappointed because her doctor doesn't prescribe an antibiotic for influenza, the doctor is not satisfying the patient and is not providing the quality of care that sells HMO reenlistment. If a 20 year-old male is embarassed when the doctor checks for testicular cancer, the HMO marketing department may be unhappy, though the doctor may be saving lives through this 30 second examination.
When the Times labels physician behavior as "profligate" without providing a carefully investigated factual basis for its serious charge, and when the White House is referenced, I have to conclude that health reform is so threatened that political forces have stooped to demonizing physicians. The American public deserves better from the White House and the Times.
Sunday, June 14, 2009
Friday, June 12, 2009
Key health care senators have industry ties
For the Yahoo presentation of the Associated Press report by Associated Press Writers, LARRY MARGASAK and SHARON THEIMER (6/11/09), click the title above. The report lists names of Senators (and, where relevant, their family members) who have serious conflicts of interest. I wonder whether the conflicts should require that they recuse themselves from the legislative process affecting health care, though recusal would throw the legislative process into complete and utter turmoil.
We won't have ethics in health care, or appropriate health care legislation, if we don't have ethics in Congress relating to health care legislation. Doctors, engaging in qualitatively similar behavior, might find themselves accused of Federal Stark Law violations, and face fines, litigation and loss of Medicare provider status and licensure.
We won't have ethics in health care, or appropriate health care legislation, if we don't have ethics in Congress relating to health care legislation. Doctors, engaging in qualitatively similar behavior, might find themselves accused of Federal Stark Law violations, and face fines, litigation and loss of Medicare provider status and licensure.
Thursday, June 11, 2009
End The AIG-like Financial Entitlement of Health Insurers
President Obama and his advisers have announced, with great press coverage, that they have found a way to save $300 million a year from health care expenditures for the next 10 years. Simple multiplication shows that this - miraculously - amounts to $3 billion over 10 years for this element of his reform plan, certainly no small amount.
Let's compare the savings announced by Obama with what could be saved by reigning-in insurance company administrative overhead. If we are about to spend about $3 trillion a year on US health care, and Medicare and other government expenses account for half, that leaves another $1.5 trillion for non-government health expenditures. If half a trillion is spent outside traditional health insurance,HMOs, PPOs and others, that leaves about $1 trillion a year passing through the coffers of the insurance company. If (an approximation) 25% of a significant number of insurance company expenditures go to administrative overhead, wiping out that overhead might save much more than $250 million dollars (perhaps as much as $250 billion?) a year (minus a modest amount for true administrative overhead - comparable to Medicare and Kaiser Permanente). And in addition, if there was one central source of payment for all "insured" health services, the cost of physicians' offices submitting bills might be reduced from over $5 per bill to less than $1.00 per bill through increased efficiency. Net savings would dwarf the $300 million per year trumpeted by Obama for his plan. The difference is that this money would have come from the same insurers who have met, in private conference in Senator Kennedy's offices, and with President Obama, who are significant political campaign contributors, and who are running shameless (covert?)advertising on television aimed at frightening Americans away from serious health reform.
The other really big important difference is that this savings could be plowed into buying health care for Americans, instead of perpetuating the AIG-like attitude of insurers that they are entitled to be made profitable by the sweat of small businesspeople and other working Americans.
Let's compare the savings announced by Obama with what could be saved by reigning-in insurance company administrative overhead. If we are about to spend about $3 trillion a year on US health care, and Medicare and other government expenses account for half, that leaves another $1.5 trillion for non-government health expenditures. If half a trillion is spent outside traditional health insurance,HMOs, PPOs and others, that leaves about $1 trillion a year passing through the coffers of the insurance company. If (an approximation) 25% of a significant number of insurance company expenditures go to administrative overhead, wiping out that overhead might save much more than $250 million dollars (perhaps as much as $250 billion?) a year (minus a modest amount for true administrative overhead - comparable to Medicare and Kaiser Permanente). And in addition, if there was one central source of payment for all "insured" health services, the cost of physicians' offices submitting bills might be reduced from over $5 per bill to less than $1.00 per bill through increased efficiency. Net savings would dwarf the $300 million per year trumpeted by Obama for his plan. The difference is that this money would have come from the same insurers who have met, in private conference in Senator Kennedy's offices, and with President Obama, who are significant political campaign contributors, and who are running shameless (covert?)advertising on television aimed at frightening Americans away from serious health reform.
The other really big important difference is that this savings could be plowed into buying health care for Americans, instead of perpetuating the AIG-like attitude of insurers that they are entitled to be made profitable by the sweat of small businesspeople and other working Americans.
Saturday, June 6, 2009
Read Paul Krugman's "Keeping Them Honest."
My rule is not to waste words. Just read "Keeping Them Honest" in The New York Times, Friday June 5, 2009, p. A21. Krugman's short message is: "1) Don't Trust the insurance industry" and " 2) Don't trust the insurance industry.
To which I can only add, as a physician and as a former active attorney who negotiated with insurers and had to deal with their failures to deliver what was promised, Krugman is right.
To which I can only add, as a physician and as a former active attorney who negotiated with insurers and had to deal with their failures to deliver what was promised, Krugman is right.
Thursday, June 4, 2009
Take A Politician To the ER Day
If we want to get serious about health care reform, I suggest that Americans ask their local, state and national politicians to join them in a visit to a local hospital emergency department on Sunday, September 6, 2009. Let's call it "Take A Politician To the ER Day."
How Can A Boiler Explosion Instruct Health Care Reform?
FATAL EXPLOSION IN CLAIFORNIA (sic):
"Three are killed and scores injured when a boiler explodes beneath a drug store and a dress shop in San Jose, California. Customers, counters and merchandise are hurled through a huge hole torn in the floor of the drug store; both shops are completely wrecked."
As we learn from the newsreel description (http://www.buyoutfootage.com/pages/titles/blacktype/pd_nr_titles/pd_newsreels63_003.html) a fatal boiler explosion occurs when the engineers' assumptions underlying the plans used to design the boiler were wrong but in their arrogance, the designers failed to question their calculations' validity, when the implementation was faulty, when the specifications were not precise leaving room for serious error, when the boiler was operated at too high a pressure, when the maintenance crew did not check safety valve operation at frequent intervals, when the operators of the boiler assumed that the safety valve would blow off steam at time of need, and when no person involved in the premises in which the boiler is located conceives of a fatal explosion, and so no reasonable emergency plans are made.
When I read the economic justification for Obama's health reform, I my impression was that the economists' calculations were grounded on uncertain speculation, that the outcome was determined before the analysis was done, that there was a lack of specificity, and that the risks of disaster if the analysis is used as a justification for proceeding, are too high and too dangerous for a great many Americans who have or will develop serious health problems and will be unable to secure appropriate care under the high-pressure Obama reform package.
A "plan" that does not reference serious ethical issues, is not a plan. A "plan" that doesn't discuss hard issues concerning our need to provide high quality care to all, is not a plan. A "plan" that damages the most vulnerable workers in the United States, hourly health care workers, and decimates their ranks in an unrealistic expectation that saving money on their wages and benefits, will provide the springboard for the massive employment growth strangely predicted by the economic analysis suggests not a plan, but a major group-think disorder. A "plan" that does not confront the concrete reality of people being unable to purchase the drugs prescribed for them because they can't afford them (even at Walmart), is wishful thinking.
Watch out for a fatal explosion when high pressure reform, unrealistically generated, lays waste to our health care system and to those who depend on ethical high quality health care in order to live another day. But beware, the economists' gauges are faulty so you may not be warned until it is too late.
"Three are killed and scores injured when a boiler explodes beneath a drug store and a dress shop in San Jose, California. Customers, counters and merchandise are hurled through a huge hole torn in the floor of the drug store; both shops are completely wrecked."
As we learn from the newsreel description (http://www.buyoutfootage.com/pages/titles/blacktype/pd_nr_titles/pd_newsreels63_003.html) a fatal boiler explosion occurs when the engineers' assumptions underlying the plans used to design the boiler were wrong but in their arrogance, the designers failed to question their calculations' validity, when the implementation was faulty, when the specifications were not precise leaving room for serious error, when the boiler was operated at too high a pressure, when the maintenance crew did not check safety valve operation at frequent intervals, when the operators of the boiler assumed that the safety valve would blow off steam at time of need, and when no person involved in the premises in which the boiler is located conceives of a fatal explosion, and so no reasonable emergency plans are made.
When I read the economic justification for Obama's health reform, I my impression was that the economists' calculations were grounded on uncertain speculation, that the outcome was determined before the analysis was done, that there was a lack of specificity, and that the risks of disaster if the analysis is used as a justification for proceeding, are too high and too dangerous for a great many Americans who have or will develop serious health problems and will be unable to secure appropriate care under the high-pressure Obama reform package.
A "plan" that does not reference serious ethical issues, is not a plan. A "plan" that doesn't discuss hard issues concerning our need to provide high quality care to all, is not a plan. A "plan" that damages the most vulnerable workers in the United States, hourly health care workers, and decimates their ranks in an unrealistic expectation that saving money on their wages and benefits, will provide the springboard for the massive employment growth strangely predicted by the economic analysis suggests not a plan, but a major group-think disorder. A "plan" that does not confront the concrete reality of people being unable to purchase the drugs prescribed for them because they can't afford them (even at Walmart), is wishful thinking.
Watch out for a fatal explosion when high pressure reform, unrealistically generated, lays waste to our health care system and to those who depend on ethical high quality health care in order to live another day. But beware, the economists' gauges are faulty so you may not be warned until it is too late.
Tuesday, June 2, 2009
EMBARGOED UNTIL TUESDAY, JUNE 2 THE ECONOMIC CASE FOR HEALTH CARE REFORM EXECUTIVE SUMMARY
The White House has released its argument supporting its version of health care reform (whatever that version might be). For the link to the entire document, click this blog's title above. Below, are the document's assumption and conclusions. Careful reading will help readers to determine whether this is an analysis based on complete and valid assumptions and whether the sketchy "plan" is more than a preliminary specification for rearrangement of the Titanic's deck chairs, lacking the specificity which would bring the lobbyists for disadvantaged irate major players in health care storming into the capitol.
"Assumptions. In this analysis, we assume that all of the savings to the Federal government take the form of deficit reduction. The assumption is a reasonable approximation. In the absence of reform, rising health care costs will cause unsustainable increases in the deficit. Using the savings from reducing the growth of health care costs to prevent these increases is essential to our long-run fiscal health. This section implicitly assumes that the costs of expanding coverage, which we discuss in the next section, would be covered by budgetary savings above and beyond the “curve benders” that are the focus of this analysis and by revenue increases. This is consistent with the President’s budget, which identified particular savings in the Medicare program and proposed specific revenue measures to pay for health care reform. In addition, over an extended period, the costs of expanded coverage are much smaller than the resources freed up by slowing cost growth. For these reasons, even if a small part of the costs of expanding coverage were paid for out of the savings resulting from slowing cost growth, this would have only a minor effect on the analysis we present....
"VII. CONCLUSION
The American health care system is on an unsustainable path. Expenditures as a share of GDP are already substantially higher than in other developed countries, and are projected to grow rapidly in the next three decades. This growth threatens to have a devastating impact on the growth in workers’ take-home pay and the government budget deficit. It is also likely to increase the number of Americans without health insurance from its already very high level and thus undermine the health of our population.
Successful health care reform will slow the growth rate of health care costs, maintain choices of doctors and health plans, and expand coverage. Slowing the growth rate of costs by 1.5 percentage points per year would have a dramatic impact on the trajectory of health care expenditures as a share of GDP over time. Slowing the growth rate of costs by a smaller amount (0.5 or 1.0 percentage point per year) would have smaller, but still important effects.
Our analysis shows that successful health care reform would have major benefits for the U.S. economy. Over time, the slowing of cost growth through increased efficiency would bring about substantial increases in Americans’ standard of living. It will also prevent devastating increases in the budget deficit and raise capital formation. We estimate that slowing health care cost growth by 1.5 percentage points will increase real GDP in 2030 by nearly 8 percent relative to what would happen without reform. We also find that slowing cost growth is likely to lower the unemployment rate consistent with steady inflation by roughly one-quarter of a percentage point for an extended period.
The net welfare effects of expanding coverage to the uninsured are also likely to be very large—probably in the range of $100 billion each year. Genuine reform will also likely increase labor supply, reduce job lock, and aid small businesses. . . .
The kind of reform that will bring about these economic rewards will not be easy. It will require truly game-changing innovations in many areas. But, if we can bring about such changes, there will be substantial benefits to American households, businesses, and the economy as a whole."
"Assumptions. In this analysis, we assume that all of the savings to the Federal government take the form of deficit reduction. The assumption is a reasonable approximation. In the absence of reform, rising health care costs will cause unsustainable increases in the deficit. Using the savings from reducing the growth of health care costs to prevent these increases is essential to our long-run fiscal health. This section implicitly assumes that the costs of expanding coverage, which we discuss in the next section, would be covered by budgetary savings above and beyond the “curve benders” that are the focus of this analysis and by revenue increases. This is consistent with the President’s budget, which identified particular savings in the Medicare program and proposed specific revenue measures to pay for health care reform. In addition, over an extended period, the costs of expanded coverage are much smaller than the resources freed up by slowing cost growth. For these reasons, even if a small part of the costs of expanding coverage were paid for out of the savings resulting from slowing cost growth, this would have only a minor effect on the analysis we present....
"VII. CONCLUSION
The American health care system is on an unsustainable path. Expenditures as a share of GDP are already substantially higher than in other developed countries, and are projected to grow rapidly in the next three decades. This growth threatens to have a devastating impact on the growth in workers’ take-home pay and the government budget deficit. It is also likely to increase the number of Americans without health insurance from its already very high level and thus undermine the health of our population.
Successful health care reform will slow the growth rate of health care costs, maintain choices of doctors and health plans, and expand coverage. Slowing the growth rate of costs by 1.5 percentage points per year would have a dramatic impact on the trajectory of health care expenditures as a share of GDP over time. Slowing the growth rate of costs by a smaller amount (0.5 or 1.0 percentage point per year) would have smaller, but still important effects.
Our analysis shows that successful health care reform would have major benefits for the U.S. economy. Over time, the slowing of cost growth through increased efficiency would bring about substantial increases in Americans’ standard of living. It will also prevent devastating increases in the budget deficit and raise capital formation. We estimate that slowing health care cost growth by 1.5 percentage points will increase real GDP in 2030 by nearly 8 percent relative to what would happen without reform. We also find that slowing cost growth is likely to lower the unemployment rate consistent with steady inflation by roughly one-quarter of a percentage point for an extended period.
The net welfare effects of expanding coverage to the uninsured are also likely to be very large—probably in the range of $100 billion each year. Genuine reform will also likely increase labor supply, reduce job lock, and aid small businesses. . . .
The kind of reform that will bring about these economic rewards will not be easy. It will require truly game-changing innovations in many areas. But, if we can bring about such changes, there will be substantial benefits to American households, businesses, and the economy as a whole."
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