Saturday, December 27, 2008

Insurer Is Sued Over Liver Transplant -

Insurer Is Sued Over Liver Transplant -

"The family of a 17-year-old leukemia patient has sued the health insurance giant Cigna over her death in 2007 after the company initially refused to pay for a liver transplant."

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Friday, December 26, 2008

Wow! Bill Moyers Journal . BEYOND OUR DIFFERENCES | PBS


A terrific show examining the similarities of faiths around the world. Social justice, the common good and the Golden Rule are key.

You can also go straight to the website of the film:

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Friday, December 19, 2008

More Uwe, 'cause it's fun!

Lecture slides from a Reinhardt talk from 2003. Worth it for the Christmas card alone (about 5 slides in).

This is why they say never to agree to follow Uwe at a conference.


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U.S. Health Care Costs, Part V: Can Americans Afford Medicare? - Economix Blog -

U.S. Health Care Costs, Part V: Can Americans Afford Medicare? - Economix Blog -

"Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here and here."

I was taken to task on Sermo for quoting Uwe Reinhardt, so I felt obligated to post some new Uwe!

And to give him his own topic, too!

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Graphic: How Class Works - New York Times

Graphic: How Class Works - New York Times

I was trying to find an update for a previous post on income distribution in the US, and found this nice, interactive graphic from the NY Times web site. Have fun.


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Tuesday, December 16, 2008

A Structural Description of Social Health Insurance

A structural description

When one moves from this inside view to a more detached, outsider

s perspective, SHI systems can be described in more structural terms. This structural understanding incorporates seven core components that exist across all eight studied countries, and that can be considered to comprise the organizational kernel of an SHI system.


Risk-independent and transparent contributions

The raising of funds is tied to the income of members, typically in the form of a percentage of the members wages (sometimes up to a designated ceiling). This has two equally important characteristics. First, contributions or premiums are not linked to the health status of the member. If a member has a spouse and/or children, they are automatically covered for the same income-related premium and under the same risk-independent conditions. Second, contributions or premiums are collected separately from state general revenues. Health sector
funding is transparent and thus insulated from the political battles inherent in public budgeting.

Sickness funds as payers/purchasers Premiums are either collected directly by sickness funds (Austria, France, Germany, Switzerland) or distributed from a central state-run fund (Israel, Luxembourg, the Netherlands) to a number of sickness funds (Belgium employs both methods). These funds are private not-for-profit organizations, steered by a board at least partly elected by the membership (except France and Switzerland), and usually with statutory recognition and responsibilities (Israel is an exception). The rules under which these sickness funds operate typically are either directly established by national legislation (Austria, France, Germany, Luxembourg, the Netherlands, Switzerland) and/or tightly controlled through a state regulatory process (Israel) (Belgium is an exception). The sickness funds use the revenues from members’ premiums (health tax in Israel) to fund collective contracts with providers (private not-for-profit, private for-profit, and publicly operated) for health services to members.

Solidarity in population coverage, funding, and benefits package Depending on the country, 63 per cent (the Netherlands) to 100 per cent (France, Israel, Switzerland) of the population are covered by the statutory sickness fund system. In countries with less than 100 per cent mandatory participation, typically it is the highest-income individuals who are allowed (Germany) or required (the Netherlands) to leave the statutory system to seek commercial
health insurance on their own (small exceptions exist for illegal immigrants, for people with objections by principle and for civil servants). Funding for all members is equalized either within national state-run pools (Israel, the Netherlands); within regional government (Austria) or foundation-based (Switzerland) pools; through mandatory risk-adjustment mechanisms (Belgium, Germany, Israel, the Netherlands); or through state subsidies (Belgium, France). In all eight SHI systems, the state requires the same comprehensive benefits package for all

Pluralism in actors/organizational structure SHI systems incorporate a broad range of organizational structures. Both within as well as between SHI countries, the number and provenance of sickness funds may vary widely, based on professional, geographic, religious/political and/or non-partisan criteria. Nearly all hospitals, regardless of ownership, and nearly all physicians, regardless of how they are organized (solo practice, group practice etc.) have contracts with the sickness funds and are part of the SHI system. Professional medical associations, municipal, regional and national governments, and also suppliers such as pharmaceutical companies are all seen as part of the SHI system framework.

Corporatist model of negotiations
Negotiations typically occur at regional and/or national level among ‘peak organizations’ representing each health sub-sector involved. This corporatist framework enables the self-regulation and contract processes to proceed more smoothly, with substantially more uniformity of outcome and substantially lower transaction costs. A corporatist approach among a group of ‘social partners’ (sick funds, health professionals, provider groupings and supplier groupings)
is also consistent with policy-making arrangements in other parts of the social sector in the seven studied European countries (less so in Israel).

Participation in shared governance arrangements
As befits the pluralist configuration described just above, SHI systems typically incorporate participation in governance decisions by a wide range of different actors. The most visible manifestation is the traditional process of selfregulation by which sickness funds and providers negotiate directly with each other over payment schedules, quality of care, patient volumes and other contract matters. Medical associations, hospital associations and other professional groups frequently have some decision-making responsibilities as well.

Individual choice of providers and (partly) sickness funds
Members of sickness funds can usually seek care from nearly all physicians and hospitals. In six of the eight studied systems, a referral to see a specialist is not required (Israel and the Netherlands are exceptions). Increasingly, members can also choose to change their sickness fund (Austria, France and Luxembourg are exceptions).

These seven characteristics – risk-independent contributions, sickness funds as
payers, solidarity, pluralism, corporatism, participation and choice – comprise
what is described in many writings about SHI systems as the ‘core structural
arrangements’ (Glaser 1991; Hoffmeyer and McCarthy 1994; Normand and
Busse 2002). Combined, they can be taken as the institutional mechanics of how
an SHI system is organized.

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Monday, December 15, 2008

Los Angeles Times: Tom Daschle has his own health plan

Los Angeles Times: Tom Daschle has his own health plan:

"Daschle is urging a far more aggressive push by those advocating systemic change.

'This means going on the offensive,' he wrote in 'Critical,' his recent book about healthcare, in which he singled out drug makers and insurers as potential obstacles to a successful overhaul.

'We cannot assume that the public recognizes the distortions and fallacies peddled by the reform opponents; we have to educate people on the emptiness of the anti-reform rhetoric,' he said.

Daschle has even suggested using the Senate's rules to prevent opponents from filibustering healthcare legislation, a move that one senior Republican staff member warned would make it 'extremely difficult' to get any GOP support for major reform.

Daschle, who declined to be interviewed, has specific -- and potentially controversial -- ideas about how to reshape the healthcare system.

Among other things, he envisions a new federal agency, which he calls a Federal Health Board, with the authority to set guidelines for what treatments and procedures are most cost-effective.

Daschle argues that the board, which would have authority over federally funded healthcare programs such as Medicare, would insulate medical decisions from political meddling by Congress and could help design a system for achieving universal coverage.

He also has called for a mandate to require all Americans to get health insurance and for the creation of a public insurance program to cover people who don't get private insurance."


"Taking another page from Daschle's political playbook, the president-elect carefully framed a healthcare overhaul as an economic necessity and a moral imperative.

'Day after day,' he said, 'we witness the disgrace of parents unable to take a sick child to the doctor, seniors unable to afford their medicines, people who wind up in emergency rooms because they have nowhere else to turn.' "

The Federal Health Board sounds NICE. That's a good thing.

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My comment to

I am an intensive care physician. I am also involved in organized medicine at a high level.

15 years ago, if you had asked a group oh physicians which healthcare reform they would chose and offered them the British national Heath Service model, a German Social Health Insurance style system, a French Single Payer system or keeping our current system and just tinker around the edges using our current private health insurance system, most would have chosen tinkering.

Now I don't believe that is the case. Now, the current system is dismissed out of hand by most physicians as a reasonable choice as is, frankly, the British system. But now, my colleagues ask me about those other systems, particularly the German style SHI system.

Physicians are data driven. We see that our outcomes are poor compared to every modern Western Democracy and we pay exorbitantly for it and our system is unfair.

The one thing that alarms me, personally, is that the German and French systems seem to be dismissed out of hand for political "reality". We have to reach out to the health care professionals in this country and teach them about the alternatives available to us and they will join us in real healthcare reform.

A little evidence to back me up:

There's more at


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Saturday, December 13, 2008

Real Health Care Reform in 2009 - Brookings Institution

Real Health Care Reform in 2009 - Brookings Institution:

If you click on the link above, it will take you to the page for the event at Brookings. I learned a lot from it. Below, I've pulled interesting quotes from the transcript which may be useful at some point in the near future. My comments are in italics, the quotes are regular font.

Opening Remarks: Political Prospects for Reform - Sen. Max Baucus

The link to Baucus' "Call to Action in 2009" Website, and some analysis from the National Journal.

He didn't say much new here, just that we were in a crisis and he wanted a bipartisan solution.

Panel 1: Opportunities for Improving Health Care » (.mp3)
Donna Shalala – Moderator
Michael Porter, Harvard Business School
Don Berwick, Institute for Healthcare Improvement
Carolyn Clancy, Agency for Healthcare Research and Quality

Berwick: "the big problem of value that Mike refers to. I disagree slightly with Michael although it's only because I'm wrong and haven't understood him thoroughly yet, but I also think the problem is cost. It's total cost. It is manifestly possible for a Western democracy to give all the care its population needs for about 10 percent of GDP. It is possible. You can't say it's not possible because it's being done. We're at 16 percent or 17 percent. We're wasting probably 40 percent or 30 percent of the dollars we're putting into health care. That's true and I don't understand, Michael I know will come at me on this, why we just don't target that as an aim, reduce the total cost. Thirty percent waste easily in our system. I think he wants to get there by working on quality and value and that's probably right, but don't take your eye off the ball. "

Berwick: "...integrated care for chronic illness and the gaps there in. The Commonwealth Fund is now our lead, I guess, scrutinizer of that problem. Seventy percent of costs go into chronic illness care. Probably half of it is pure waste. And a lot of it happens because we don’t have the integrated flows that we need for a restructured care system.
"The third really might be American exceptionalism. It’s our inability to learn from successful models outside of this country. Countries that function with better care than we have; we are 19th out of 19. That’s OECD data, that’s what Senator Baucus said and he’s right, compared to countries that are functioning at 60 or 70 cents on our health care dollar.
"We’ve got to learn from these other models and not throw them away because we assume that stuff like that doesn’t work here. It will. It’s our decision, what we choose we can choose to change."

Berwick: "My wife is Under Secretary for Energy in Massachusetts and she has taught me about decoupling in the energy world where utilities now in at least 20 states or so, aren’t paid for volume. They can make as much money by saving a kilowatt as by making one. We need to do that with care. You ought to be able to somehow treat an empty bed as an asset. Right now we don’t do that at all. "

Hmmm. No quotables from anybody except Don Berwick...

Panel 2: Policy Reforms to Improve Health Care Delivery » (.mp3)
Mark McClellan – Moderator
Alice Rivlin, Brookings
Elliott Fisher, Dartmouth
Denis Cortese, Mayo Clinic

Fisher: [Highlights first barrier as system fragmentation.]

"The second barrier I would highlight is out current payment system, which is truly toxic, supply driven, and will be hard to change. "

..."And many of the current initiatives, whether it’s pay for value, episode-based payments as they are currently being considered or even the medical home model. Risks reinforcing the fragmentation in our current system and certainly won’t slow the growth of health care costs. As long as we can have specialists continue to purchase new services, see their patients at their current rates the medical home will be powerless to deflect the growth of spending in the acute sector on the specialist side. Without creating that medical neighborhood that they can work effectively in. "

"The third barrier I’d highlight is that I think many of our policy initiatives currently conflict with each other or compete with the provider’s attention and are an increasing burden to the practice of clinical medicine. Whether it’s performance measure, pay-for-performance initiatives, they’re all going and not thought through carefully. So let me make three suggestions as to strategies that we might consider. "

Rivlin: "The title of this session is rather polite. It’s getting to higher quality, better value, and sustainable coverage. That’s a polite way of saying the current system is wasteful, excessively costly, often provides poor quality, even harmful care and the number of the uninsured is growing and we have to do something about that.

"The number one imperative in health care reform is moving toward the system that gives us more health for the large number of dollars we already spend and slows the arte of growth of health care spending for the future. If we can’t do that, we won’t have a sustainable health insurance system and we won’t have a sustainable Federal budget.

"Now it’s often said that we cannot effectively reduce the rate of growth of health care spending until we move to universal coverage. And we’re all for universal coverage, but the opposite is more nearly true. We cannot get to universal coverage, we cannot expand coverage unless we find a way to control costs and improve quality. Adding more claimants to the existing system will only exacerbate the current problems of rapid increase in spending and poorer quality.

"So where to start? Well, we actually already have universal coverage and a single payer in a huge piece of the system called Medicare. And I think we must, initially, use Medicare to lead the way to a system that rewards effective treatment and discourages waste and inefficiency. "

Cortese:"Every Congressman you talk to when you say what’s the number one problem in healthcare in the United States? They say "we’re not getting what we pay for." The unfortunate answer to that statement is "oh, yes you are." That’s the saddest component. We are -- this country has gone so far to make sure we are paying for non-value that somebody’s got to stand up and say it is time to pay for value.

[Review of 4 principles of reform of Mayo found here.]

Panel 3: Talking About Reform: New Directions for Involving the Public » (.mp3)
Susan Dentzer, Health Affairs – Moderator
Neil Newhouse, Public Opinion Strategies
Stan Greenberg, Greenberg Quinlan Rosner
Jim Guest, Consumers Union

Dentzer: "...most of us will remember the famous comment made by an elderly woman who ran into Senator -- then Senator -- John Breaux in an airport in Louisiana and applauded him for his efforts on health reform, and then said to him "but Senator, whatever you do, don’t let the government take over my Medicare." This being thought of as the emblematic piece of public opinion on healthcare reform and underscoring Congressman Barney Frank’s famous statement that "people complain about the politicians, but the voters aren’t so hot either."

"The Commonwealth Fund surveys show three-quarters of the public or more wanting a completely rebuilt healthcare system or one that is improved in major ways.

Newhouse: "One-third of Americans believe the healthcare system in the country needs to be radically changed, 51 percent reformed, just 12 percent status quo. Remarkable numbers and from that we would obviously take that there is a significant sentiment for change. Next one. And yet 71 percent say they’re happy with their own healthcare compared to 24 percent say they believe that the healthcare in the country is going well.

Greenberg: "I remember the failing of the Clinton healthcare plan. I remember the battle over trying to get the unions to support us in order to advance the plan. It was a struggle to get union support until it was decided whether Cadillac healthcare plans were going to be taxed –- I think it was $5,000 at the time, but the issue of taxing Cadillac plans kept unions back. Unions, many of the industrial unions sector were not that sure that this plan was one they wanted to support, were in a totally different place. Those, as we’ve seen in the auto industry, know that their insurance is at risk; the service sector unions are much stronger.

"When we tried to get the DNC and others to pay for ads for support of the plan, we had –- it was a couple million dollars for the total effort on behalf of the healthcare plan. We’re dealing with a total shift of civil society, which I think puts this in an entirely different context. The Clinton healthcare plan died in committee. Can you imagine in this environment if you came forward with a healthcare plan and it got in trouble in the Energy and Commerce Committee and Nancy Pelosi or the leadership of the Congress or the president saying okay, that’s the end of healthcare, we’re not going to go forward?

"When you get to healthcare, people are more nervous and more risk reverse about the kinds of changes you make. So, while we’re going to operate in an environment which I think there will be momentum for change and they’ll be engagement of public to move the process forward, the public is not -– almost half the public wants to move boldly and half wants to move carefully, and, so, you’ve now a risk averse public which obviously creates opportunity for those who don’t want to see it happen.

MR. NEWHOUSE: "But don’t you think if they do this in an initial wave that it’s got to be step-by-step, piecemeal, kind of incremental approach rather than major healthcare reform? And how do they sell it? Do they sell it as major healthcare reform or do they sell it as steps to improve healthcare?"

MR. GREENBERG: "No, I think it’s got to be big change, but it may be that it’s step-by-step over 10 years to get there, but I think they got to know where it’s going. "

MR. NEWHOUSE: "You know what’s interesting is just as we showed poll data here showing how difficult it is, the political environment actually makes this a little bit easier for Barack Obama. The mood in the country –- Stan and I have polled all over the world. We had, what, 10 percent right direction in this country? There are a few countries around the world that had lower than 10 percent of people saying the country is heading in the right direction.
The sense for change here is extraordinary, and Barack Obama has the opportunity to really use that mandate and begin to form this mandate for change. "

Panel 4: Moving Forward on Reform: Discussion and Political Perspectives » (.mp3)
Mark McClellan and Chris Jennings – Moderators
Sen. Richard Burr
Sen. Sheldon Whitehouse

Jennnings: "And I have to say that even this issue of the uninsured has started to -– people are starting to understand that people aren’t looking at the uninsured as an issue as it relates to the more obliged so much as the cost shifting that is associated with the uninsured, and they’re also looking about the uninsured about if the real problems in our healthcare system are our inability to prevent and to manage the chronically ill population substantially well, how do you do that without covering populations in significant ways? How do you do prevention well? How do you do chronic care management well? How do you eliminate cost shifting? "

SENATOR WHITEHOUSE: "I'm particularly honored to be here with my colleague Senator Burr. The group that he's referring to could probably be called the bookends club, because it's me and Sherrod Brown and Richard and Tom Coburn, and I would suspect that 90 percent of the Senate is between us, and -- nevertheless, we have had very, very good discussions, and as you've just heard Richard lay out his top four principles, there's not a whole lot that I would disagree with in those.

"I think that we are at a new place. I think that the entrenchment that would well establish politically around the finance and access questions dating back to '93 has been somewhat made a little bit out of date by this whole new discussion that we've had, particularly today, about quality and prevention and delivery system reform. And so there aren't positions that are as hardened there as in the old debate, and I think we're also getting a new sense of urgency that is common on both sides of the aisle. "

Whitehouse: "In Rhode Island, you know, years ago when I started the Quality Institute, we brought the Keystone Michigan Intensive Care Unit forum to Rhode Island to go statewide, and the hospitals were, you know, okay with the idea, but they said look, you've got to understand our problem. We can do this. It'll probably cost us $400,000 per intensive care unit per year. We think we might save $8 million per intensive care unit per year, at which point I interrupt, you know, ignorantly, and say well, great, 20-to-1 payback, go. And they say, no, no, no, you don't understand, that $8 million comes off our top line, and the $400,000 comes out of our very scarce cash flow, and at the bottom line there's really very little benefit to us for doing this. When we understand that problem, which is one of the fundamental problems of the quality failure we're having, then we can set up the right mechanisms to get it addressed so that when a hospital is willing to invest in quality improvement, it sees a reward for that, and there are a lot of different ways to get to it, but I think the most important thing is we've got to have -- as I said earlier, we've got to have situational awareness about what our problem is. Once we do that, some of the stuff actually is pretty simple and straightforward, and I agree with you, I don't think Congress should get right down into the final details. "

The bulk of this discussion is between the two Senators and relates to process inside the Congress.

Cheers, Chris

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Monday, December 8, 2008

Video Links: Woodrow Wilson School of Public and International Affairs

I did want to make these links available because they are really, really informative for the upcoming debate. The MP3s of these are still here.

Woodrow Wilson School of Public and International Affairs WebCasts

September 12, 2008
"Access to Universal Health Care - Pt 1: Introductions, and Healthcare in New Jersey"
WM Video:

Pt 1: WELCOME AND OPENING REMARKS - Richard F. Keevey, Director, Policy Research Institute for the Region, Woodrow Wilson School, Princeton University - Daniel A. Notterman, MD, MA, Department of Molecular Biology, Princeton University UNIVERSAL HEALTH CARE IN NEW JERSEY - Senator Joseph Vitale, Senator and Chairman, Health, Human Services and Senior Citizens Committee, New Jersey State Senate - Heather Howard, Commissioner, New Jersey Department of Health and Senior Services - Christine Stearns, Vice President for Health and Legal Affairs, New Jersey Business and Industry Association

September 12, 2008
"Access to Universal Health Care - Pt 2: Healthcare Worldwide"

WM Video:

Pt 2 UNIVERSAL HEALTH CARE WORLDWIDE - Uwe Reinhardt, PhD, James Madison Professor of Political Economy, Princeton University - Maggie Mahar, PhD, Fellow, The Century Foundation - Ezekiel Emanuel, MD, PhD, Chair, Department of Bioethics, National Institutes of Health

September 12, 2008
"Access to Universal Health Care - Pt 3: Keynote"
Speaker(s): Len Nichols

WM Video:

Pt 3 LUNCHEON SPEAKER - Len Nichols, PhD, Director, Health Policy Program, New America Foundation

September 12, 2008
"Access to Universal Health Care - Pt 4: Statewide Efforts"

WM Video:

Pt 4 UNIVERSAL HEALTH CARE IN THE NATION – THE MASSACHUSETTS EXPERIENCE & OTHER STATEWIDE EFFORTS - Nancy Turnball, PhD, Associate Dean for Educational Policy, Harvard School of Public Health - Merrill Matthews, Jr., PhD, Director, Council for Affordable Health Insurance, Washington DC - Brian Rosman, Director of Research, Health Care for All

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Friday, December 5, 2008

The Evidence Gap - British Balance Benefit vs. Cost of Latest Drugs -

The Evidence Gap - British Balance Benefit vs. Cost of Latest Drugs -

"RUISLIP, England — When Bruce Hardy’s kidney cancer spread to his lung, his doctor recommended an expensive new pill from Pfizer. But Mr. Hardy is British, and the British health authorities refused to buy the medicine. His wife has been distraught.

“Everybody should be allowed to have as much life as they can,” Joy Hardy said in the couple’s modest home outside London.

"If the Hardys lived in the United States or just about any European country other than Britain, Mr. Hardy would most likely get the drug, although he might have to pay part of the cost. A clinical trial showed that the pill, called Sutent, delays cancer progression for six months at an estimated treatment cost of $54,000.

"But at that price, Mr. Hardy’s life is not worth prolonging, according to a British government agency, the National Institute for Health and Clinical Excellence. The institute, known as NICE, has decided that Britain, except in rare cases, can afford only £15,000, or about $22,750, to save six months of a citizen’s life.

"British authorities, after a storm of protest, are reconsidering their decision on the cancer drug and others.

"For years, Britain was almost alone in using evidence of cost-effectiveness to decide what to pay for. But skyrocketing prices for drugs and medical devices have led a growing number of countries to ask the hardest of questions: How much is life worth? For many, NICE has the answer. "

What a great piece. I've been hearing more and more about NICE lately, with this being the most visible publication on it.

As I've said elsewhere under the "Rationing" label, I would much rather have a fair, national or regional, system of objective analysis by scientists deciding on what care we offer to patients than the current method. The current method being everything for everyone all the time until we can peel the oncologists (sorry, guys! Others of us are guilty, too!) off the patient. Our current method also includes allowing Lilly to lobby for new reimbursement codes to pay for Xigris, or Zimmer to get Medicare to pay twice as much for a "women's" TKR and assorted other pieces of free market capitalism.

But the US' favorite method of rationing care, of course, is by income. Don't have it, don't get it.

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Wednesday, December 3, 2008

The Health Care Blog: POLICY: Oh Canada

The Health Care Blog: POLICY: Oh Canada

"This article is about Canada's health system and its relationship to the US health policy debate. It is not meant to be an endorsement of Canada's system, or an endorsement of single payer for the US."

Very well done, but a few years old. Most of the information is still pertinent. Very nice, very detailed compare/contrast piece on US vs. Canadian Healthcare systems.

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Monday, December 1, 2008

Excluded Voices : CJR:

Excluded Voices : CJR::

The last lines:

"TL: What will it take to change the terms of today’s health care conversation?

TM: In my judgment, it would take the president of the United States to lead a fundamental re-examination of the presently limited debate over health care reform."

An interesting piece, debunking, or at least wuestioning, the conventional wisdom of why the 93-94 Clinton reform failed and what needs to be done to have a better debate this time. That would be our job: make sure the debate is open, honest, inclusive and data driven.

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Consensus emerging on universal healthcare - Los Angeles Times

Consensus emerging on universal healthcare - Los Angeles Times:

"Also unresolved is what mechanisms might be created to force individuals or businesses to get insurance, both potentially contentious subjects.

And few have tackled how the government will control costs and set standards of care, proposals that raise the unpopular prospect of federal regulators dictating which doctors Americans can see and what drugs they can take.

'There are some very big questions and some very big stumbling blocks,' said Stuart Butler, vice president for domestic policy at the conservative Heritage Foundation, who has been watching the healthcare debate for three decades.

'Once you get into the details, the consensus is going to vanish pretty quickly, I suspect,' he said.

At the same time, advocates for a single-payer system, including the California Nurses Assn., have vowed to continue pushing the idea next year along with many Democrats on Capitol Hill."

Our work is cut out for us. We must not let anything to be placed "off the table," as single payer was suggested to be elsewhere in this article, without a fight.

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World Health Organization Report on Social Health Insurance Systems

in Western Europe.

It's 313 pages, so, no, I haven't read it yet, but I want the resources at our fingertips when the time comes...

From the introduction:

The concept of social health insurance (SHI) is deeply ingrained in the fabric of health care systems in western Europe. It provides the organizing principle and a reponderance of the funding in seven countries – Austria, Belgium, France, Germany, Luxembourg, the Netherlands and Switzerland. Since 1995, it has also become the legal basis for organizing health services in Israel. Previously, SHI models played an important role in a number of other countries that subsequently changed to predominantly tax-funded arrangements in the second half of the twentieth century – Denmark (1973), Italy (1978), Portugal (1979), Greece (1983) and Spain (1986). Moreover, there are segments of SHI-based health care funding arrangements still operating in predominantly tax-funded countries like Finland, Sweden and the United Kingdom, as well as in Greece and Portugal. In addition, a substantial number of central and eastern European (CEE) countries have introduced adapted SHI models since they regained control over national policy-making – among them Hungary (1989), Lithuania (1991), Czech Republic (1992), Estonia (1992), Latvia (1994), Slovakia (1994) and Poland (1999).

Also, I'm going to add a topic Tag of "Social Heath Insurance" and cross tag all my "Bismarckian" ones so that it becomes clear they are the same thing.

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Sunday, November 30, 2008


TPC Events | events_022908:

February 29, 2008

Sponsored by the Tax Policy Center and the American Tax Policy Institute
Falk Auditorium, Brookings Institution 1775 Massachusetts Ave., NW Washington, DC

"Download paper summaries.

Download conference transcript

Listen to the audio recordings:

* Session One

* Session Two
* Session Three"

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Monday, November 24, 2008

Medical Professionalism in the New Millennium: A Physician Charter -- Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine* 136 (3): 243 -- Annals of Internal Medicine

Social Justice and a commitment to a fair distribution of finite resources has always been a core of who we are as physicians and as human beings. With the renewed emphasis on professionalism in medicine, it is being reintroduced as part of the core of our values as physicians. This is very welcome, but does not sit so well with some of our more conservative colleagues, as you'll see below.

Medical Professionalism in the New Millennium: A Physician Charter -- Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine* 136 (3): 243 -- Annals of Internal Medicine:

"Fundamental Principles:

"Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

"Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

"Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. "

In the next section, A Set of Professional Responsibilities:

"Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.

"Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."

Response Letter in Annals of Internal Medicine, by Christopher Lyons, in part:

"In the charter's preamble, the concept of medicine's contract with society is discussed. To a large extent, the obligations of physicians to society in that contract are nicely laid out in the subsequent discussion. Given that a contract is usually created between two parties and each party has an obligation to the other, what is society's responsibility to physicians? As highly trained, caring members of society, aren't physicians entitled to certain assurances of financial stability? Should we be expected to withstand ongoing efforts to politicize the health care industry in attempts to garner votes while balancing the federal budget? Must we continue to withstand repeated attacks from trial attorneys who have little interest in the facts of a medical case and are interested only in the payoff? "

Another, by Jerome Arnett, in whole:

"I read with interest the article on medical professionalism in the new millennium (1), which proposed a new code of conduct for physicians comprising three principles and 10 responsibilities. As a proposed code of ethics, the charter is untenable for several reasons. Two of the three principles conflict. Patient welfare is predicated on individual rights while social justice is based on group rights (those of "society"). Since individual rights and group rights are mutually exclusive, the physician can follow one of these two principles but not both (2). In addition, at least 2 of the 10 responsibilities (public advocacy and just distribution of finite resources) place the interests of others ahead of those of the patient. Physicians will be less likely to subscribe to an ethical code that does not have the welfare of the patient as its highest objective.

"Equality of outcome is an undesirable and unattainable vision that invariably results in the loss of patients' rights. Only under socialism (government medicine or corporate socialized medicine) are health care resources finite, so that they must be rationed or justly distributed. Under other circumstances, the provision of services"necessary" or "unnecessary"to one patient does not diminish the resources available for others.

"The commitment to maintaining trust by managing conflicts of interest forbids physicians to pursue private gain or personal advantage. How then is it ethical for a group of physicians such as the Medical Professionalism Project to weaken our code of ethics in order to promote a political agenda (improving "the health care system for the welfare of society," promoting "the fair distribution of health care resources," or ensuring social justice)? These proposed changes in our time-honored, patient-centered ethics will worsen, not improve, the dilemma of today's physicians, who already are challenged by new technology, changing market forces, problems in health care delivery, bioterrorism, and globalization. But even more ominous, medicine without effective, patient-centered ethics is no longer a profession but merely a tradewhich was its status in ancient Greece before the Oath of Hippocrates.

Reference number 2 is:
2. Vazsonyi B. America's 30 Years War: Who Is Winning? Washington, DC: Regnery; 1998:79.

Two of the authors, Drs. Cruess and Cruess, reply, very diplomatically:

"Although Dr. Arnett's points are well taken, the charter is not a code of ethics, nor is it intended to detract from or supplant the Hippocratic tradition that has long enriched medicine's history. It is a statement of contemporary responsibilities—medicine's understanding of its obligations under today's social contract. We strongly disagree that individual rights and group rights are mutually exclusive and that "the physician can follow one of these two principles but not both." We do not underestimate the difficulty of reconciling the two sets of responsibilities but believe passionately that medicine must attempt to do so. The alternative is for someone without medical knowledge or expertise to determine the societal rights in health care and how they are to be reconciled with the rights of individual patients. Do we really wish this to occur, or do we believe that it is better for individual physicians and their organizations to use their expertise to try to achieve the proper balance? The charter suggests the latter course. It does, however, state that physicians must put the welfare of the individual patient first, thus reaffirming our traditional fiduciary responsibilities. Our duties to individual patients must be carried out with a knowledge of the impact of our own decisions on the wider society, which we also serve. We also disagree that the allocation of resources to one patient does not diminish the resources available to others under a market-driven system. The attempts at cost containment seen throughout the world, no matter what the nature or structure of the health care system, indicate that this is not true. There is no question that contemporary physicians are expected to serve both their patients and society.

"A second point of some importance refers to "equality of outcome." We are not sure that equality of outcome can be termed "undesirable," as Dr. Arnett stated, but certainly such an objective is unrealistic. Nowhere does the charter advocate equality of outcome as an objective.

"Dr. Arnett interprets the charter as forbidding physicians' pursuit of private gain or personal advantage. Nowhere does it so state. The conflicts of interest section states that physicians must deal with these conflicts in an open and transparent way. We cannot eliminate conflicts of interest, but we must ensure that our integrity is preserved as we cope with and manage them and recognize the consequences of our decisions.

"We agree with Dr. Arnett that without effective patient-centered ethics, medicine is no longer a profession. As already mentioned, the charter is not a code of ethics but a freely given statement of medicine's commitments and responsibilities, essentially outlining where we should stand in complex times. It is aimed at restoring the feeling of pride in the profession and public trust that all observers have agreed is so essential to the proper functioning of a profession and distinguishes it from a trade."

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Thursday, November 20, 2008

Health Care Reform Podcasts

5 Podcasts on Healthcare Reform found at the University Channel Web Site

Access to Universal Health Care Pt 1: New Jersey (Podcasts/Podcasts)
...Daniel A. Notterman, MD, MA, Department of Molecular Biology, Princeton University UNIVERSAL HEALTH CARE IN NEW JERSEY - Senator Joseph Vitale, Senator and Chairman, Health, Human Servi...

Access to Universal Health Care Pt 2: Worldwide (Podcasts/Podcasts)
Pt 2 UNIVERSAL HEALTH CARE WORLDWIDE - Uwe Reinhardt, PhD, James Madison Professor of Political Economy, Princeton University - Maggie Mahar, PhD, Fellow, The Century Foundation -

Access to Universal Health Care Pt 3: Keynote (Podcasts/Podcasts)
Pt 3 LUNCHEON SPEAKER - Len Nichols, PhD, Director, Health Policy Program, New America Foundation

Access to Universal Health Care Pt 4: Statewide Efforts (Podcasts/Podcasts)
Pt 4 UNIVERSAL HEALTH CARE IN THE NATION – THE MASSACHUSETTS EXPERIENCE & OTHER STATEWIDE EFFORTS - Nancy Turnball, PhD, Associate Dean for Educational Policy, Harvard School of Pub

How the Next President Can Deliver on Healthcare Reform (Podcasts/Podcasts)
...ive Vice President for Policy, AARP; Robert Moffit, Senior Fellow, Heritage Foundation; Joanne Silberner, Health Policy Correspondent, National Public Radio (Sep 26, 2008 at the National Pr...

For this last one, I highly recommend watching the Video so you can see Uwe Reinhardt's slides.

I will give them a listen soon, but didn't want to lose the links...

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Tuesday, November 18, 2008

Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries -- American College of Physicians, -- Annals of Internal Medicine

Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries -- American College of Physicians, -- Annals of Internal Medicine:

"This position paper concerns improving health care in the United States. Unlike previous highly focused policy papers by the American College of Physicians, this article takes a comprehensive approach to improving access, quality, and efficiency of care. The first part describes health care in the United States. The second compares it with health care in other countries. The concluding section proposes lessons that the United States can learn from these countries and recommendations for achieving a high-performance health care system in the United States. The articles are based on a position paper developed by the American College of Physicians' Health and Public Policy Committee. This policy paper (not included in this article) also provides a detailed analysis of health care systems in 12 other industrialized countries.

Although we can learn much from other health systems, the College recognizes that our political and social culture, demographics, and form of government will shape any solution for the United States. This caution notwithstanding, we have identified several approaches that have worked well for countries like ours and could probably be adapted to the unique circumstances in the United States."

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Monday, November 17, 2008

Think Big - Campaign Stops Blog -

Think Big - Campaign Stops Blog -

"1) “Make no little plans. They have no magic to stir men’s blood and probably will not themselves be realized.” So said Daniel Burnham, the architect and urban planner (and fellow Chicagoan).

In health care, big plans are necessary not only to motivate people but as a matter of sound policy. The health care system is broken. It is not enough to just add more people to a broken system. Health care reform must reorganize the system to deliver higher quality care while keeping costs under control. Incremental change that just covers more people will not be sustainable. Reform must include changing the delivery system and how we pay for care. The health care system needs major surgery, not more Band-aids.

More important, as negotiation specialists note, you don’t begin with your compromise position. If we have to settle for incremental Band-aids, it should be only as a last resort."

A nice piece about how tinkering around the edges of healthcare is doomed to failure, and by failure, I mean more of the same in our dysfunctional system.

The companion piece, "Think Small" is typical right wing dreck. "Don't do too much," "Americans are conservative" , "Americans are happy with the current system", the usual stuff - you know, eschewing reality for the conservative echo chamber. The comments, however are anything but an echo chamber. No mercy shown, so well worth reading them!


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Wednesday, November 12, 2008

Health Beat: Herzlinger’s Meme on Switzerland and Consumer Driven Medicine

Health Beat: Herzlinger’s Meme on Switzerland and Consumer Driven Medicine:

"Yet even if the Swiss are not the world’s most conscientious health care shoppers, individuals in Switzerland spend about a third less on health care than the average American. How can that be? Time and again, Herzlinger repeats the meme that consumer choice accounts for Switzerland’s lower costs. And if she says it often enough, without citing evidence, no doubt many Americans will believe her. But it just isn’t so.

Even a cursory glance at Switzerland’s system reveals that government-enforced price controls on virtually everything from drugs to doctors keeps a lid on health care inflation. The fees that providers charge “are negotiated by the cartel-like associations of insurers and clinicians under the watchful eye and heavy hand of government” Reinhardt observes. And “since all insurers are bound to the same prices for ambulatory care, and prices are negotiated between insurers and individual hospitals for inpatient care,” there is little room for the consumer to affect prices by comparison-shopping.

Finally, when it comes to ensuring that the Swiss are receiving effective care, Switzerland's Federal Department of Home Affairs establishes the formulary for prescription drugs that it believes give good value, while the Federal Department of Home Affairs decides which lab tests and medical devices are to be covered by compulsory insurance.

In the end, Reinhardt suggests that “what is most impressive about the Swiss health system is the role tight government regulation plays . . . . One can plausibly argue that this regulation is chiefly responsible for both the high quality and (relative to the United States) low cost of Swiss health care.” Determined to make the case for consumer-driven care, Herzlinger takes the opposite view arguing, in today’s WSJ that the Swiss government’s web of regulations, requiring “an extensive minimum benefit package,” while “micromanaging” both prices and products is precisely what keeps Switzerland from becoming the unfettered consumer’s paradise that she would like to see. "

A nice overview of the Swiss system and a Bronx cheer to the crapola that is "Consumer Driven Healthcare". Thanks to Ian Welsh of Firedoglake for the link from his piece on the Baucus Plan...

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AMA It's not just about us

AMA It's not just about us:

Some excerpts from the address of AMA President Nancy Nielsen:

"We need fundamental change in our health care system for ourselves, for our patients, for our nation. Right now annual health care costs exceed $2 trillion. That's 16 percent of our nation's GDP. Costs are estimated to reach $4 trillion and 20 percent of GDP in 10 years.

Right now, annual health care costs are the number one reason for bankruptcy. Right now, Americans get about half the preventive services that are recommended. Right now, we rank 19th among 19 developed countries in mortality that could be helped by health care. That means deaths that might have been prevented by health care. Nineteenth out of 19.

Forty-six million Americans have no health insurance, and another 29 million are underinsured. Those 75 million Americans are delaying or failing to obtain preventive care.

In our nation's sick economy, job losses mean the loss of health insurance. Just yesterday, the government reported that employers cut 240,000 jobs in October alone. And so far in 2008, some 1.2 million jobs have been lost.

We as a nation have to do some serious soul searching. We are the most innovative, resilient, determined, self-reliant and creative nation in the world. Our health care system ought to be the best in the world but currently it is not.

Today we pay twice what other countries with better health outcomes pay. But we rank last or next to last in many health indices. And, that's compared with Australia, Canada, Germany, New Zealand and the United Kingdom.

Now, we can try to protect the status quo. But the status quo is not serving patients well, and doctors are angry and unhappy. It is high time we do something about it and I'm not talking about single-payer. I am, however, talking about comprehensive change. I'm talking about responsible change that builds on the strengths of the current system. Isn't it time to build a bridge to a new and better health system? A system where patients are better served and physicians are happier and more fulfilled in their work?"


"Do you remember this pivotal question during one of the presidential debates? "Is health care a right, a privilege or a responsibility?" Whatever our personal convictions on the answer to this question, the broader population seems to be moving fairly rapidly to the view that health care is a right.

But who will pay for this right, if that's the country's decision? Who will define the parameters of this right to health care? Because everyone cannot have everything, and society should not have to provide everything, nor can it afford to do so.

Take education as an example of setting parameters. Our society has decided that K-12 education is a right, but post-secondary education is a privilege and a responsibility.

Defining parameters for health care "rights" and "responsibilities" will require society's honest deliberation and some difficult decisions. For sure we have to define the expectations of personal responsibility. What is fair to expect the individual to do? What should be up to the individual, and what should be society's concerns?"


"As we participate with the rest of society in this debate, we cannot allow the discussion to descend into ideology and inflammatory labels. If we do, if we allow reason to be trumped by rhetoric, then we will have lost our chance to shape the change, to build the bridge to a better health system.

So I ask you, are we prepared to participate in that societal debate? Because the debate is going to happen. This is not just about doctors. It is not just about us. But physicians and patients will have to live with the outcomes. That's why we have a central role to play.

We all use the commons and that is why we all have to do our part to protect it. Make no mistake, I am not in favor of a single-payer system. I am in favor of a health care system that works better for all of us, patients and physicians.

We're in a time when our country is demanding change. We need change. Let's harness that energy for our patients and ourselves. For sure, this is for us - we have to remove the sand from our shoes. But it is for so much more than us."


"In many countries, when people are scared, they turn to government for protection. Even though many do not trust Washington politics, they may see it as their only option. There is great concern in our country. We need to help calm those fears. We need to embrace our role as healers in a time of need. We need to help craft a solution that is based on our professional ethics--one that is equitable and just, one that builds on the strengths of our system, addresses current weaknesses, and allows us to regain the joy and simple dignity of caring for our patients. "

Please go check out the whole thing. Credit where credit is due. It is a remarkable statement from the the AMA President.

I am concerned by the last paragraph I quoted, however. My goal is to turn to my government for fairness, and it is not our of fear, it is out of anger at the mismanagement of our system and at the giant sucking sound, to quote Ross Perot, that emanates from our insurers, Pharma, and ourselves that makes our system so inefficient. So, I hope this is not the line in the sand that the AMA is drawing, that a solution based upon strong government regulation is off the table.

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