Tuesday, April 29, 2008

Speech assignment

In January we will have a new president. That means one of them will be promoting their health care plan from the White House and one of them from the Senate.

And Jeff Sherman will be our congressman and will have to work to decide how health care reform will proceed for the next 4 to 8 years.

You higher small-business people. Every year we get our annual health-insurance bill and our jaws drop. Some of us are paying for ourselves and our families only in some of us are doing our best to keep covering our employees without bankrupting our businesses. If you like me, you may find it tough enough to keep up with your quarterly tax estimates the least you know what to expect health-insurance costs are rising at astronomical rates and we can't vote the CEO of mega health out of office for doing such a lousy job

Maybe his/Peabodybusiness is doing well enough that there is no big deal for him.

when you have all the money we spend in the US and divided among the 300 million of us who spend about twice as much per person is a typical European country or Japan or Australia area and a recent study showcased in the Wall Street Journal found as we may be wasting as much as $1.2 trillion a year of $2.2 trillion dollars a year we spend on health care . Don't get me wrong I'm an intensive care doctor and I oversee minor gurgles everyday. Our high-tech care are cancer and heart care are second to none in the world. But neither is Belgium's. Or New Zealand. Or Switzerland. Something's got to give.

I can tell you what no bombs and Clinton's proposals might look like, and they may be dead on right.. Change makes everyone nervous, but I can also tell you this if they look like they're handed down from on high like the 10 Commandments, there are a lot of people who are going to do their damnedest to stop any change whatsoever good or bad. Peabody would be one of those guys. On the other hand if you support Jeff he knows we need change and he also knows change won't happen unless we have a national conversation about what what Americans want what changes will work for America.

That's why Jeff Sherman will be calling on the president for health care reform commission to bring together is only for POTUS can the best and the brightest to head a national conversation of healthcare

Okay other notes:

I'm really just add the parts about Kennedy, the best and the brightest, NASA was an administration and why don't we have faith in government anymore, why does the commission sound like a joke to us and it should represent the best of America.

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Saturday, April 26, 2008

Interview with Dr. Calloc'h, of France's Chambre du Medicine

Interview with Dr. Louis-Jean Calloc'h, Auditeur au Conseil National de l'Ordre des Médecins and Secrétaire-Génèral de l'Association Médicale Française and Director of International Affairs for the Chamber of Medicine of France

In France, "a 'G-P Specialist' is a G-P who practices and has a quite exclusive and verified good and permanent practice in general medicine. Not an other not referenced opposed verified practices: homeopathie, acupuncture, psycological-consultations. The others are simply G-P."

Economic pressure is forcing physicians to become specialists. In the past in France you were able to go to any physician but there became restrictions on access to cost restrictions. The GP is still the gatekeeper. A patient is not allowed to go directly to a cardiologist or other specialist without using the gatekeeper function. This is a recent change.

Training is changing. In the past, it required approximately 8 or nine years of training to become a GP. It took two or three years after that to become a specialist. But now GPs are becoming specialists: I think he's saying here that a GP can get additional training at the University to get further qualifications. It's not clear to me the difference between GPs with a traditional training versus true specialists. It sounds like it might be that one becomes a GP specialist in cardiology and therefore sees more patience with party logic problems but they are still not true cardiologist specialists. And they still perform a gatekeeper role before the patients get to the true specialist. It sounds like the GP and the GP specialist both are in charge of handling the ministerial and medical record-keeping work in the system. Keeping the dossier, as Dr. Calloc'h says.

Dr. Calloc'h notes that patients can be put on the list, for example, of diabetics who require more advanced care. These patients can then go see an endocrinologist directly several times a year. There are limits to how many erect visits the patient can get. The idea is apparently to make the primary interface with a primary care physician can not a specialist. He specifically said that specialists such as cardiologist and endocrinologists do not perform primary care functions.

The GP is the person who interfaces with the single-payer entity. The GP also develops a care plan. This plan may specify a number of visits to a specialist. If the patient exceeds the number of visits they then have to pay out of pocket. There is a list of from 20 to 22 diseases that are specifically supposed to be managed with a plan by the GP. He gave several examples including hypertension and diabetes obesity and some others that I didn't catch. It sounds like these patients that also signed a contract with some details of their management plan including specialist visits. Now here Dr. Calloc'h indicates that a specialists may actually act as a GP for some of these patients. He called it the "Reseau," which is a kind of managed care contract. The réseau is a contract that the GP or specialist also signed with the single-payer and agrees to manage the patient. The Medical Society, Chambre Du Medicine, seems to be advocating for this approach, but the trade unions do not. The chamber also would rather see multiple players for more competition. It's not clear to me what the competition would center around.

Dr. Calloc'h: "The "Assurance Maladie or CNAM" is so powerfull in France that, today, there is quite no economique competition with other public or prived medical care insurance. Only one entity to negociate with."

Trade unions. It took a little while for me to figure this out, but the physicians have trade unions. So, when he was talking about trade unions, he was asked a talking about the physician trade unions who sound to me to be the advocates for the physicians on economic matters. As opposed to the chamber of medicine, whom he represented, who were more the professional watchdogs and ethical watchdogs. For the trade unions, the single-payer is a big problem because there is only one entity to negotiate with. This seems to be why they would like to see multiple payers.

Generally people pay the physician. Poor people get a card to excuse them from payment. If the patient is without means and has complicated multiple illnesses, apparently one has to appeal to the single-payer for credit on the card for more frequent visits etc. For the people who do pay, currently the fee is €22 but this will be rising this coming year. Interestingly, it sounds like the complexity or time of the visit is immaterial. He said a 4 or 5 minute visit gets the same fee is a more complicated visit. However the more you do, such as EKGs or blood work, the fees accumulate. He said something in here about the patient's then getting reimbursed by the single-payer, but only about €17 for a visit. So this functionally works out to a five euro co-pay. Some patients buy supplementary insurance so that even that small co-pay is taken care of.

He makes the point that GPs are expected to be able to do everything except the most dangerous of procedures. He feels that this is asking too much and that some physicians make the mistake of being too proud and believing that they can do anything. And this is something that the chamber of medicine handles, and it's role as what we would call a state Board of medicine. France has civil sanctions, administrative sanctions and penal [criminal?] sanctions. The Chamber of Medicine is responsible for the professional sanctioning. It is akin to a state Board of Medicine however it is run from within the profession and not from the state or national government. Complaints can come from patient to patient organizations or from other doctors. Apparently the complainants and lawyer decide whether something can be handled through sanctions or through civil law, which sounds like medical liability action. He says that he feels this is having a chilling effect particularly on young physicians who are now more worried about liability. He also indicates that this is slowing the activity of the Chamber of Medicine because of concerns with the civil liability aspect of the case. So where they might act quickly in the past they now are more circumspect and take more time to make a decision. Dr. Calloc'h feels the France is about 15 years behind where the US is regarding medical liability. He indicates that France now has lawyers who specialize in finding medical liability cases much as we have here in the US.

[Dr. Calloc'h has updated me that he thinks they have nearly caught up due to their new lawyers.]

Half of physicians in France are GPs. There are limited number of specialists. This is due to specific decisions made by the single-payer, apparently. The decision was made that too many specialist made care too costly and that this had to be stopped. Apparently the thinking was that too many doctors led to many prescriptions and too many prescriptions increased the cost of care. "So stupidly, they decided 15 years ago to make the big selection(?)"-- not sure if he meant here about cutting training or something else.

And what of the most pressing concerns of physicians under the French system? The pressure of lawyers and prescription restriction. The first is obvious, the second simply refers to pressure to prescribe generics and formulary restrictions on expensive medications. And the patients are specifically asking for the newer, better medication. The single-payer keeps statistics on each physician and they know when you prescribe to many antibiotics for example. They will then send someone out to talk to you. If this keeps happening you can get an administrative sanction. This can then turn into an economic sanction where they single-payer will refuse to reimburse patients for their visits to you. Obviously this is fairly severe. It sounds like much of this takes place in the context of your position neighborhood and what others in your area are prescribing or not.

The Chamber of Medicine is apparently not allowed to advocate politically. Political advocacy therefore takes place either through the universities or the trade unions (and maybe the specialty societies?). There are trade unions for GPs and for specialists also. It sounds like you typically belong to your specialty's trade union and its academic society.

I will keep updating this as I receive clarifications from Dr. Calloc'h.

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Monday, April 21, 2008

Household Income, US Census Data

Household Income-2005--Part 1:
"Table HINC-05. Percent Distribution of Households, by Selected Characteristics Within Income Quintile and Top 5 Percent in 2006

[Source: U.S. Census Bureau, Current Population Survey, 2007 Annual Social and Economic Supplement. Numbers in thousands. ]

I always get confused when I hear people talking about middle income families/households, and it alwasy seems to me that if you are in the DC or other elite groups, $100K or even $200K puts you squarely in the middle class.

As you can see by the table (if you can't read it, follow the link to the Census Bureau), the true middle, is between $37K and $60K for the true middle quintile and between $20K and $97K for the 3/5 in the middle.

Now, just to follow up on something I heard McCain (and the usual propogandists agains National Health Insurance systems of any kind) say is that you'll be taxed to death. Now, if you are in the middle 3/5, and you are paying, for argument's sake, $12K for healthcare (either out of your wages or paying it yourself), how, again, do you lose by adopting a single payer or
Bismarck style insurance plan?

And I guess I learned something from
Frontline and Uwe Reinhardt: I have to add "Bismarckian Insurance Plan," to my categories/tags.


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Sunday, April 20, 2008

Sunday Forum: Medicare for all ("Australian Rules")

Sunday Forum: Medicare for all:

"Some Americans believe that countries like Australia, Canada and nearly all of Europe have 'socialized medicine.' For many, it's a vague concept that often conjures images of uncaring doctors, dirty government clinics, cracked plaster, crowded waiting rooms and really old magazines. And if you don't like it -- well, you can't fight city hall.

But that's just a dark fantasy. Australia has attractive offices and hospitals, great doctors, state-of-the-art care and, most importantly, quick and easy access to high-quality emergency care.

It's not socialized medicine, it's Medicare for all. You are born with it, you die with it and you get all the care you need in-between. Everyone has insurance, all the time."

Dr. Flanders is a psychiatrist in Pittsburgh and does a nice job of contrasting healthcare in the US and Australia. I've written for the Sunday P-G, so I know they really limit the length of your column. I hope this means we can hear more from her in the future.

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Friday, April 18, 2008

FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung-mei cheng | PBS

FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung-mei cheng PBS

Wow. I can't say enough about this interview. It is so on the mark in so many ways, and it is a pleasure to hear knowledgeable people discuss comparative international healthcare like this.

There are great bits on the real meanings of "socialized" medicine, vs socialized insurance, the German (!) perspective on the dignity of every person, the Canadian perspective on humanism, the leadership of Tony Blair turning around a system on the rocks, how terrifically well America does in training its healthcare providers (especially doctors), but the best is Reinhardt's take on "Consumer Driven Healthcare", quoted here:

We've heard some people have proposed that a solution for America is something called consumer-driven health care. How does it work? What is it?

... Well, the name "consumer-driven health care" at this time is a deceptive marketing label. What we're really talking about is an insurance policy with a very high annual deductible -- up to $10,500 per family, and less for an individual -- and then coupled with a savings account into which you can put money out of pretax income; you don't have to pay taxes on such income.

Now, this has the advantage ... that people faced with this deductible will think twice before going to the doctor for trivial issues or drugs they don't need, etc. But of course the problem also is that they may not go when they should or may skimp on the drugs they should be using, like a blood pressure drug, so that one would have to be solved by saying preventive services will have first-dollar coverage. So you could solve that problem.

But then what I argue is, yes, it may have the economic effect of cost control, because you then would have to know the prices different doctors charge, and hospitals and pharmacies, and something about the quality. And that information at this time exists only in a few areas. The insurance companies are beginning to work on Web sites that will give you that, but it's still very primitive and fairly unreliable information. So that is why I compare it really more like thrusting someone into Macy's department store blindfolded and say, "Go around; shop smartly." ...

The other problem that I see with it, though, is it has ethical dimensions to it that people don't appreciate. If I make anything tax-deductible, then a high-income person in a high tax bracket saves more than a poor [person]. So supposing a gas station attendant and I each put $2,000 into a health savings account, and we get a root canal -- about $1,000, just the drilling. It costs me about $550 because I'm in the 45 percent bracket. The gas station attendant may, in fact, not pay federal income tax because the income is so low but may only pay Social Security, so he saves 8 cents on the dollar. So a root canal will cost me $550; will cost him $920. ...

Secondly, think of a family of two professionals, each making $140,000, close to $300,000 income, and they have, say, a $5,000 deductible. Would they deny their child anything that they think the child needs over a lousy $5,000? ... But think of a waitress who makes $25,000 with a $5,000 deductible, and her kid is sick. It will certainly make her think twice. She's likely to say, "Maybe not." So therefore we're asking the lower half of the income distribution to do all the self-rationing through prices. ...

And the third issue is this deductible. If you're chronically healthy, you don't actually ever spend as much as that; you have a tax-free savings account. If you are chronically ill, on five drugs, you're going to spend that deductible year after year. So the proposal is to shift more of the financial burden of health care from the shoulders of the chronically healthy to the shoulders of the chronically sick.

And I would say, imagine a politician coming to the people with a platform that I just described in ethical terms. ... You think that would sell? So they say, "We've got to find a better name. Why don't we call it consumer-driven health care?," and have all these deceptive labels that even George Orwell wouldn't have thought of. That is what I find troublesome. Yes, it's an approach to health care, but could you please describe it to the American people honestly, in all of its dimensions -- not just economics but information and ethics? And that's not done. ...

One answer he gave about physicians income left me with more questions that when I started:

Yes, American doctors get paid more, relative to average employees, than doctors in other nations; that is true. It's about five times average employee compensation, and in England it's about two, and in Canada it's about three. So that's certainly true.

Given the unprecedented income disparity in this country, it is hard to know what to make of these figures. Comparison to the median would have been more helpful, but I think the most interesting would be to see in which decile physicians place in each country. I will try to find that data.

This Frontline Website is a gold mine. Thanks to the indispensable CPB.

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Tuesday, April 15, 2008

FRONTLINE: sick around the world: five capitalist democracies & how they do it | PBS

FRONTLINE: sick around the world: five capitalist democracies & how they do it PBS:

"Each has a health care system that delivers health care for everyone -- but with remarkable differences."

Summaries of the five countries covered in the Frontline episode: UK, Germany, Japan, Taiwan and Switzerland.

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Frontline: Sick Around the World

Frontline: Sick Around the World

Lots to digest, and I've only begun to explore the web extras, so I post now for convenience' sake. Overall, though, TR Reid did a terrific job all around.

From the physicians' perspective, I, of course would have liked more but they only chose to do an hour. Frankly, this would have been another good use of an extended format Frontline, as they did with "Bush's War."

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Rent hikes forcing out city (Calgary, Canada) doctors

Rent hikes forcing out city doctors:

"'It's scary,' said Dr. Linda Slocombe, president of the Calgary and Area Physicians' Association, who notes that doctors, unlike most other small businesses, can't raise their prices to offset rising costs. 'In another two or three years we're going to have a real drastic shortage of family doctors.'

The study, which was commissioned by CHR last summer but only became public during a recent meeting of Calgary family physicians, comes as the city already struggles with a doctor shortage.

An estimated 200,000 Calgarians don't have a regular family physician, a problem that has been compounded by at least 41 doctors who have closed their practice in recent years.

Experts say the physicians are retiring or leaving to pursue other jobs in medicine, where they earn a good salary and don't have the hassle of operating an office."

Posting this in keeping with my "warts and all" policy of reporting the good and the bad of other systems.

BUT, does any of this not apply to PCP's in America? Can't raise our prices? The hassle of operating an office? (And they don't even have to deal with dozens of private health insurers, so they are mainly talking about the other hassles.)


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Monday, April 14, 2008

AMNews: April 21, 2008. More physicians backing national coverage -- study ... American Medical News

AMNews: April 21, 2008. More physicians backing national coverage:

"Physicians who support 'government legislation to establish national health insurance'
All specialties------------49%--------------59%
Pediatric subspecialties---71%--------------71%
Emergency medicine-----53%--------------69%
Internal medicine--------56%--------------64%
Medical subspecialties----50%--------------63%
Family medicine----------44%--------------60%
General surgery----------52%--------------55%
Surgical subspecialties----37%--------------45%

I will try to get more of the details to the original article from the April 1 Annals of Internal Medicine tomorrow, as I can't access it here at home tonight.

Update: here is the link to the Annals page. Actually not much more info there but here is the full results summary:

Results: Of 5000 mailed surveys, 509 were returned as undeliverable and 197 were returned by physicians who were no longer practicing. We received 2193 surveys from the 4294 eligible participants, for a response rate of 51%. Respondents did not differ significantly from nonrespondents in sex, age, doctoral degree type, or specialty. A total of 59% supported legislation to establish national health insurance (28% "strongly" and 31% "generally" supported), 9% were neutral on the topic, and 32% opposed it (17% "strongly" and 15% "generally" opposed). A total of 55% supported achieving universal coverage through more incremental reform (14% "strongly" and 41% "generally" supported), 21% were neutral on the topic, and 25% opposed incremental reform (14% "strongly" and 10% "generally" opposed). A total of 14% of physicians were opposed to national health insurance but supported more incremental reforms. More than one half of the respondents from every medical specialty supported national health insurance legislation, with the exception of respondents in surgical subspecialties, anesthesiologists, and radiologists. Current overall support (59%) increased by 10 percentage points since 2002 (49%). Support increased in every subspecialty since 2002, with the exception of pediatric subspecialists, who were highly supportive in both surveys.
The spin in the AMA News article is predictable (poorly worded survey questions), and, OK, fine, maybe some didn't mean exactly as they answered. We've all taken surveys, and it is true, you can only answer the question that is asked.

But look at some of these numbers because they are astounding. When 45% of physicians in surgical subspecialties (we're talking orthopods, urologists, and neurosurgeons here!) and 55% (!!!!) of general surgeons answer this way, there is a problem.

AMA Policy is against single payer. But AMA policy is determined by it's House of Delegates. This is a very democratically structured body, but frankly, delegates are far older and more conservative than all other AMA members and AMA members are older and more conservative than physicians as a whole, so this is a problem that will take a leader from within the AMA leadership to take up and champion. Which, knowing the culture a bit, would be courageous, but history making.

Putting this together with the Minnesota and Jackson and Coker surveys, we may finally be acheiving critical mass.

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Saturday, April 5, 2008

Jackson and Coker Physician Survey on "Universal Healthcare"

Survey details:

"As a result, Jackson & Coker commissioned a survey to determine the opinions of health professionals, especially practicing physicians, on the topic of healthcare reform. The survey results convey their views and advance the ongoing debate at this point in the presidential election cycle."

Jackson and Coker is a physician recruiting firm. I actually got an e-vite to this survey and took it. Most respondents were in practice 15 years or longer, making them likely significantly more Republican and "conservative," so take it with a tablespoon of salt.

I frankly didn't find many surprises in it, much like surveys done by "The Factor" or Lou Dobbs, but I did find a ray of hope in the morass:

When asked, "Should health insurance be controlled by the government or private companies?"
25% said "The Federal Government" and 39% said "Private companies with government oversight."

That gives a surpisingly large (can I say overwhelming?) 64% majority in this survey who sound like they would accept a Single Payer system in the sense of something like a Medicare-for-All system of government contracted payers.

Wow. The seeds are there.

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CITY HEALTH CLINICS NEED A BOOSTER SHOT | Philadelphia Daily News | 04/04/2008

CITY HEALTH CLINICS NEED A BOOSTER SHOT Philadelphia Daily News 04/04/2008:

"How they don't work: The system is far from perfect. According to a report released by the Philadelphia Unemployment Project last year, it can take up to five months to schedule an appointment with a doctor at a health center. Advocates say the centers need to extend evening hours and add staff to shorten waiting times. The mayor's proposed funding increase is supposed to deal with some of these issues.
One of the biggest challenges that health centers face is offering competitive salaries to attract qualified staff.

The salaries offered by the city for three critical positions - pharmacists, dentists and physicians - are relatively low when compared to industry averages.

The highest-paid pharmacist working for the city makes $77,013 - well below the national median of $103,000. The same is true for dentists who work for the city. A typical dentist makes $130,000 a year. That's significantly more than the $95,630 made by the highest-paid dentists at city health centers.

The largest discrepancy can found in the salary paid to doctors. The average physician working in a family practice makes $204,000. The highest-paid physician working for the city makes $109,820 - a difference of more that $94,000."

Just had to post this for all of those who insist we don't have to wait for healthcare in America and that "everyoine in America has access to health care."

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