Friday, December 12, 2014

JAMA Network | JAMA | Reshaping US Health Care: From Competition and Confiscation to Cooperation and Mobilization

 

In this issue of JAMA, 3 Viewpoints, by Powers et al,1 Fuchs,2 and Fisher and Corrigan,3 address problems, possibilities, and mechanisms for reshaping the US health care enterprise to better meet community needs at an affordable cost.

In their Viewpoint, Powers et al1 grapple with a question as old as democracy: How can productive collective action, which is required for a state to succeed, emerge from the factional divisions for which protection is required for democratic principles to succeed?

The founding fathers of the United States debated this vigorously. In the most famous Federalist Paper,4 Madison favored a large republic in the hands of a meritocracy to counterbalance the passions of a majority “faction” that might overwhelm legitimate minority interests. Others wanted to protect states’ powers, arguing that smaller political units could be more responsive to local groups.

Madison defined a faction as “a number of citizens, whether amounting to a minority or majority of the whole, who are united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community.”4

Health care is ground zero for this problem, and the stakes are immense. Health care is a behemoth “faction” that controls one-sixth of the US economy and distorts the nation’s economic and political future. I recently ran as a candidate for governor of Massachusetts, and, in the course of an 18-month campaign, I saw vividly the effect of this dominating industry on the opportunities for the total well-being of a population of nearly 7 million people.

JAMA Network | JAMA | Reshaping US Health Care:  From Competition and Confiscation to Cooperation and Mobilization

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Sunday, December 7, 2014

Robert Nozick, father of libertarianism: Even he gave up on the movement he inspired.

Thought I’d blogged this before, but this is from an excellent piece on Libertarianism’s most famous proponent and his own change in perspective later in life.

How could a thinker as brilliant as Nozick stay a party to this? The answer is: He didn't. "The libertarian position I once propounded," Nozick wrote in an essay published in the late '80s, "now seems to me seriously inadequate." In Anarchy democracy was nowhere to be found; Nozick now believed that democratic institutions "express and symbolize … our equal human dignity, our autonomy and powers of self-direction." In Anarchy, the best government was the least government, a value-neutral enforcer of contracts; now, Nozick concluded, "There are some things we choose to do together through government in solemn marking of our human solidarity, served by the fact that we do them together in this official fashion ..."

We're faced then with two intriguing mysteries. Why did the Nozick of 1975 confuse capital with human capital? And why did Nozick by 1989 feel the need to disavow the Nozick of 1975? The key, I think, is recognizing the two mysteries as twin expressions of a single, primal, human fallibility: the need to attribute success to one's own moral substance, failure to sheer misfortune. The effectiveness of the Wilt Chamberlain example, after all, is best measured by how readily you identify with Wilt Chamberlain. Anarchy is nothing if not a tour-de-force, an advertisement not just for libertarianism but for the sinuous intelligence required to put over so peculiar a thought experiment. In the early '70s, Nozick—and this is audible in the writing—clearly identified with Wilt: He believed his talents could only be flattered by a free market in high value-add labor. By the late '80s, in a world gone gaga for Gordon Gekko and Esprit, he was no longer quite so sure.

Robert Nozick, father of libertarianism: Even he gave up on the movement he inspired.

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Sunday, November 2, 2014

Trends With Benefits | This American Life

An amazingly helpful look into what our disability program has become. Done with the usual attention to humanity and detail as we have come to expect from This American Life.

490: Trends With Benefits

Mar 22, 2013

The number of Americans receiving federal disability payments has nearly doubled over the last 15 years. There are towns and counties around the nation where almost 1/4 of adults are on disability. Planet Money's Chana Joffe-Walt spent 6 months exploring the disability program, and emerges with a story of the U.S. economy quite different than the one we've been hearing

Trends With Benefits | This American Life

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Are Americans Finding Affordable Coverage in the Health Insurance Marketplaces? - The Commonwealth Fund

Some good graphics and a chart pack on this topic. There are losers in this – higher income individuals and families who don’t qualify for significant subsidies under the exchanges.

By the end of the first open enrollment period for coverage offered through the Affordable Care Act’s marketplaces, increasing numbers of people said they found it easy to find a plan they could afford, according to The Commonwealth Fund’s Affordable Care Act Tracking Survey, April–June 2014. Adults with low or moderate incomes were more likely to say it was easy to find an affordable plan than were adults with higher incomes. Adults with low or moderate incomes who purchased a plan through the marketplaces this year have similar premium costs and deductibles as adults in the same income ranges with employer-provided coverage. A majority of adults with marketplace coverage gave high ratings to their insurance and were confident in their ability to afford the care they need when sick.

Are Americans Finding Affordable Coverage in the Health Insurance Marketplaces? - The Commonwealth Fund

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A Direct Primary Care Medical Home: The Qliance Experience

An innovative primary care model…

Who and Where A Seattle primary care practice accepting patients of all ages, staffed by internists, family physicians, and nurse practitioners.

Core Innovations In this direct care practice, in lieu of insurance, patients pay an age-adjusted monthly fee for unrestricted, comprehensive primary care. Patients have no copayments for visits. Low overhead allows providers to have small patient panels, giving patients better access and allowing more time per visit. The objective is to shift care away from expensive specialists and hospitals.

Key Results Qliance has established a viable, sustainable business model with low overhead and patient panels about a third the size of those of the average insurance-based family physician. This has allowed patients to enjoy much greater access and clinicians to delve much more deeply into patients’ health issues, do more research on health problems, work more closely with consultants when necessary, and work more intensively with patients on health change, leading to greater engagement of and satisfaction among clinicians.

A Direct Primary Care Medical Home: The Qliance Experience

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Sunday, September 21, 2014

Why We Must Ration Health Care - NYTimes.com

Why We Must Ration Health Care - NYTimes.com:



You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.


'via Blog this'

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Thursday, September 11, 2014

In praise of placebos - Pittsburgh Post-Gazette

 

In alternative treatments, patients are told that “it will take time to regain your health.” Granted sufficient cultural authority, chiropractors and other alternative medicine practitioners could dissuade patients from risky and painful medical tests, dependence on addictive drugs and needless surgeries.

This makes what chiropractors do secondary to what they prevent. True natural healing may involve distracting patients with a good story and avoiding medical interference. Spinal manipulation at least gives patients time, reassurance and permission to recover — without a costly back surgery that often has no greater probability of success than time and encouragement. (Of course, alternative medicine can become the new dependence — and the new form of bloated expenditure — as “regaining health” creeps into ongoing treatment for “maintaining health.”)

The greater theme here is that so much of our health and well-being lies in our connection with others. My study found that people receiving care — even if it was sham therapy in a control group — showed greater improvement over those stuck on a waiting list.

The logical conclusion is that we are more resilient and more likely to recover if we have a plausible explanation of why we hurt and when the pain might end, and if we know that someone cares. How many other conditions might also require just patience, community and time to heal?

In praise of placebos - Pittsburgh Post-Gazette

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