Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker:

A damning look by Atul Gawande at the way we pay for medical care in America. The final three paragraphs of this must read article.

"Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

"In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”

"As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future."

I went to the Dartmouth Atlas web site myself and found this interesting tid-bit:

I think it fits in well with the ethos described in Gawande's article.

It is much easier to continue aggressive treatment rather than spend time having an honest discussion about the benefits and burdens of continuing treatment.


Thanks to whoever put the link up on the Howard Dean Webinar tonight!



UPDATE: This recent Archives of Internal Medicine article is particularly apporpriate:
http://archinte.ama-assn.org/cgi/content/short/169/10/954

This also, perversely, can make the hospital statistics in mortality look good, as well. As an intensivist, I can get almost ANYONE out of the the ICU and subsequently out of the hospital if I ignore the true outcome for the patient and the family: additional suffering, minimal prolongation of a life at its end, and so on.

My colleagues who do practice best EOL practices know that our ICU and hospital mortality numbers suffer, but I have no doubt that having honest discussions with my patients and families is the right thing to do. You may have heard this for your patients, “Thanks for the straight talk, Doc,” or “Nobody talked to me about my prognosis before.”

Of course, this is not new information, but we still need to do better as physicians:http://www.chestjournal.org/content/128/1/465.full?ck=nck

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QUALITY: Doctors Oppose Insurer Control Over Patient Care Decisions | New America Blogs

QUALITY: Doctors Oppose Insurer Control Over Patient Care Decisions New America Blogs:

"Some doctors have decided they are fed up and not going to take it any more.California pain specialist Dr. Bradley Carpentier is among them.

"While Republican strategists stir up fears about government meddling in health care, the San Francisco Chronicle reports on doctors like Carpentier who are concerned about insurance companies that come between them and their patients."

Go read the rest.

The EMC Research Study is here.

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Missoulian: Single-payer mentions draw cheers at Baucus-sponsored health care talk

Missoulian: Single-payer mentions draw cheers at Baucus-sponsored health care talk

The hearing ranged broadly over the possibilities for reform, but what clearly resonated for McArthur was something Baucus' chief of staff, Jon Selib, said a couple of times.

Discussing why a single-payer system of health insurance wasn't viable, Selib made reference to the more than 150 million Americans who are covered by some sort of employer-provided health care.

“A lot of people like that,” Selib said.

When the time came for questions, McArthur stood up and asked a simple question. Looking across a standing-room-only crowd of about 275, he asked how many were happy with their employer-based health insurance.Less than 10 people raised their hands.

“The number is bogus,” McArthur said. “It's not working for 95 percent of us.” McArthur drew resounding applause.

In fact, any mention of single-payer health care insurance brought raucous cheers and clapping.

Any other solution to health care reform - including Baucus' “balanced” plan that would create a mix of public and private plans - was received more coolly.

Tuesday's session was one of a handful of events Baucus is sponsoring around the state this week. He chairs the Senate's powerful Finance Committee, and is the point man on health care reform.

He did not attend Tuesday's meeting, but Selib did, and he heard what the senator himself has heard since he announced that single-payer wasn't really on the table.

As Selib worked to massage that point, one man barked out, “Oh bull----.”

Tom Roberts, president of the Western Montana Clinic and moderator at the session, asked the crowd to be civil, but the man had made his point.

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What's on my MP3 Player...

...aren't I cool?

Center for American Progress Events (Audio):


Can Health Reform Deliver for Providers?
Tuesday, April 14, 2009, 5:13:49 PM
Half-way through this and it's very good. Dr. Paulus of Geisinger is very impressive..

Medicare’s Lessons for Health Reform
Thursday, April 02, 2009, 1:04:18 PM

Health Reform: “Now is the Time for Action”
Friday, March 27, 2009, 10:59:49 AM
This features Sen. Baucus as opener, then has some good discussion with Paul Begala and Norm Ornstein and Karen Tumulty...

The Ideology and Politics of the Millennial Generation
Wednesday, May 13, 2009, 1:10:51 PM

"The Age of Stupid"
Wednesday, April 29, 2009, 12:12:33 PM

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Health Reform Without a Public Plan: The German Model - Economix Blog - NYTimes.com

Health Reform Without a Public Plan: The German Model - Economix Blog - NYTimes.com:

"What if that [public option] plan were sacrificed on the altar of bipartisanship? Would it be the end of meaningful health reform?

"Not necessarily, if the health systems of the Netherlands, Germany and Switzerland are any guide.

"None of these countries uses a government-run, Medicare-like health insurance plan. They all rely on purely private, nonprofit or for-profit insurers that are goaded by tight regulation to work toward socially desired ends. And they do so at average per-capita health-care costs far below those of the United States — costs in Germany and the Netherlands are less than half of those here."

When I get in discussions of HC reform with my friends who are more committed to a single payer solution than I, I point out that most countries we look to as exemplars of excellent universal health care do not, in fact, use the single payer model, but use some hybridized form of the Bismarckian, or Social Health Insurance model, such as Germany. This may explain why the American College of Physicians made its policy recommendations in 2007: though single payer was recommended first, a hybrid system was neck and neck and felt to be more achievable.

Dr. Reinhardt explains the overview beautifully here, and I cannot improve upon it. He, as always, provides great framing to his points that can be appropriated for the discussions you have on the topic. For more details on the German system, go here.

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Arch Intern Med -- Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954

Arch Intern Med -- Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954:

"Background Many terminally ill patients enroll in hospice only in the final days before death or not at all. Discussing hospice with a health care provider could increase awareness of hospice and possibly result in earlier use.

"Methods We used data on 1517 patients diagnosed as having stage IV lung cancer from a multiregional study. We estimated logistic regression models for the probability that a patient discussed hospice with a physician or other health care provider before an interview 4 to 7 months after diagnosis as reported by either the patient or surrogate or documented in the medical record.

"Results Half (53%) of the patients had discussed hospice with a provider. Patients who were black, Hispanic, non-English speaking, married or living with a partner, Medicaid beneficiaries, or had received chemotherapy were less likely to have discussed hospice. Only 53% of individuals who died within 2 months after the interview had discussed hospice, and rates were lower among those who lived longer. Patients who reported that they expected to live less than 2 years had much higher rates of discussion than those expecting to live longer. Patients reporting the most severe pain or dyspnea were no more likely to have discussed hospice than those reporting less severe or no symptoms. A third of patients who reported discussing do-not-resuscitate preferences with a physician had also discussed hospice.

"Conclusions Many patients diagnosed as having metastatic lung cancer had not discussed hospice with a provider within 4 to 7 months after diagnosis. Increased communication with physicians could address patients' lack of awareness about hospice and misunderstandings about prognosis."

First, having these conversations with patients is the right thing to do for a multitude of reasons, not the least of which is our duty to help our patients weigh the benefits and burdens of medical treatment. The reduction of unwarranted suffering is hard to over estimate.

Second, imagine the economic impact of doing the right thing. No rationing, just having the appropriate conversations with our terminally ill patients.

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Why is single-payer health care off the table? -- themorningcall.com

Why is single-payer health care off the table? -- themorningcall.com:

"As an advocate for the Pennsylvania Council of Churches, I am charged to advocate on behalf of a single-payer system -- a system I support personally, as well. The council has taken this position because it is the only system that meets all the criteria outlined in our health-care position statement: health care that is universal, continuous, affordable to individuals, families, and for society, and able to enhance health and well-being by promoting access to high-quality care. Despite polling data that consistently shows more than 50 percent support for a national plan or at least coverage for emergencies, we continue to see this option shunned.

"Now, even the prospect of a public option is disappearing before our eyes. How many more people must die, suffer permanent damage because a system has failed them, lose their homes or be driven into bankruptcy before our elected officials will reject complicity in a system that lines the pockets of the few to the pain and detriment of the many? "

[The Rev. Sandra L. Strauss is director of public advocacy for the Pennsylvania Council of Churches, with offices in Harrisburg.]

And the PA Council of Churhes weighs in via an op-ed in the Allentown Morning Call.

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U.S. Physicians’ Views on Financing Options to Expand Health Insurance Coverage: A National Survey

U.S. Physicians’ Views on Financing Options to Expand Health Insurance Coverage: A National Survey:

MAIN RESULTS

1,675 of 3,300 physicians responded (50.8%). Only 9% of physicians preferred the current employer-based financing system. Forty-nine percent favored either tax incentives or penalties to encourage the purchase of medical insurance, and 42% preferred a government-run, taxpayer-financed single-payer national health insurance program. The majority of respondents believed that all Americans should receive needed medical care regardless of ability to pay (89%); 33% believed that the uninsured currently have access to needed care. Nearly one fifth of respondents (19.3%) believed that even the insured lack access to needed care. Views about access were independently associated with support for single-payer national health insurance.

CONCLUSIONS
The vast majority of physicians surveyed supported a change in the health care financing system. While a plurality support the use of financial incentives, a substantial proportion support single payer national health insurance. These findings challenge the perception that fundamental restructuring of the U.S. health care financing system receives little acceptance by physicians.

This is the article referenced in the post below this one on physicians and physicians' organizations views on health care reform. The full article is here and in PDF.

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"Doctors, too, are ready for CHANGE" | The Register-Guard | Eugene, Oregon

"Doctors, too, are ready for CHANGE" The Register-Guard Eugene, Oregon:

"For most of the last century, no single group was a bigger obstacle to universal health care than organized medicine. Today, perhaps no single group stands more united in support of some form of universal coverage.

"Before their lost battle against President Lyndon Johnson and Medicare, the opposition of major medical organizations and individual physicians guaranteed doom for various state and presidential efforts to establish either a national health plan or other means to achieve universal health insurance.

"Now, surveys reveal that overwhelming numbers of physicians resent the current crazy patchwork health care system, which fixes their reimbursements, regulates and too often denies patient care, and piles physicians with paperwork so unending and from so many directions that the average doctor has little time left over to challenge the status quo.

"Add to all this the frustration arising from working for no pay to coordinate care and provide care after hours, from struggling with the cost of health care insurance for their own employees, and from seeing their uninsured and underinsured patients go without recommended care, and what emerges is widespread physician support of radical reform.

"More than four-fifths of physicians now agree that our health care system either needs fundamental changes or should be rebuilt completely."

Keep reading, this is a nice summary of where the specialty societies are coming down on health care reform, and it is encouraging...

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Medical News: AMA: Membership Bounces Back Slightly - in Meeting Coverage, AMA from MedPage Today

Medical News: AMA: Membership Bounces Back Slightly - in Meeting Coverage, AMA from MedPage Today:
"According to Dr. Maves, the AMA signed up 3,300 more physicians in 2005 than it did in 2004, which is a 2.5% increase. The increase, he said, came in regular members plus physicians in their first or second year of practice and military physicians—all membership categories that reflect 'real, practicing physicians.'

"There are more than 850,000 MDs in the United States and 56,000 osteopathic physicians. About a quarter of this total, including interns, residents, and retirees, who pay sharply reduced dues, are members.

"The increase in members added $500,000 to AMA coffers, but represented only a small fraction of the $28.1 million operating profit that Dr. Maves reported for 2005.

"Regular members pay $420 a year. Physicians in the second year of practice pay $315, military physicians pay $280, and first-year physicians pay $210.
"Overall, AMA membership in 2005 was 244,005, a number that includes medical students, who pay $20 a year to join the AMA and residents who pay $45 year.

"The AMA will not, however, release the number of practicing physicians who are members, but using the 3,300 figure to calculate the total membership the math works to where 132,000 members in the 'real, practicing physicians' were in this category in 2004 and 135,300 in 2005.

"'The first year I was here, we lost 17,000 members, so this is definitely a victory,' Dr. Maves said in an interview. But he added that the AMA has still not increased its market share which was 26% in 2004.

"That stands in stark contrast to the 80% membership market share claimed by national medical specialty societies."

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PNHP : Good links in letter for members

Dear PNHP Colleagues,

This Friday evening (May 22) the Bill Moyers Journal on PBS at 9 p.m. EDT will feature a discussion with Dr. David Himmelstein, co-founder of PNHP, and other single-payer advocates, asking the question "why isn't a single-payer plan on the table in Washington?"

This important media event is emblematic of a recent surge in media interest in the single-payer alternative (see below) - a surge in large part fueled by the bold and courageous acts of civil disobedience undertaken by PNHP members and others before the Senate Finance Committee earlier this month.

Yesterday the conservative editorial board of the Times-Union in Albany, N.Y., made an impassioned appeal to Congress to put single payer on the table.

Dr. Margaret Flowers, one of the first persons arrested by the committee for speaking up for single payer, explains why she did so in this op-ed in the Baltimore Sun. She has given radio and newspaper interviews almost every day since her arrest.

Others who took part in the D.C. actions have been profiled in the media, too: see, for example, these portraits of Dr. Judy Dasovich and Dr. Carol Paris.

Dr. Paul DeMarco, writing in the Spartanburg (S.C.) Herald Journal, explains why, as a conservative, he supports single payer and the principle of mutual aid. (His op-ed ran directly alongside an opposing view by Sen. James DeMint, R-S.C.).

In their May 16 letter to The New York Times, Drs. Arnold Relman and Marcia Angell, past editors of the New England Journal of Medicine, explain how "We don't need more money; we need a new system." In another recent NYT letters column, Dr. Laura Boylan writes, "As long as the logic of our system is set by a huge for-profit multi-payer bureaucracy, we will continue to get low value on the health care dollar."

This is just the tip of the iceberg. For example, Dr. Himmelstein was on NPR's Diane Rehm Show Monday, along with Sen. Bernie Sanders (I-Vt.) and others.
.................
I thought this was worthwhile to pass along...

UPDATE: Fixed the links! Sorry about that!

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Public Plan Options: Strong, Weak, and MRP?

Courtesy of Health Affairs Blog, and Harold Luft:

"The two options are the “strong” and the “weak” versions of a public plan, referring not to the strength of the proposals, but the power of the public plan. The “strong” version, as advocated by Jacob Hacker, among others, is a near-clone of Medicare adapted for those under age 65. It uses Medicare’s buying power in setting fees for providers, thereby keeping down the premium cost relative to private plans without such leverage. Not surprisingly, providers and private insurers vigorously oppose the idea, which they see as inevitably leading to a “Medicare for all” single-payer system. The proposal has other important features largely tied to parallel changes that need to be legislated for Medicare. Holding out for the “strong” plan risks having a political stalemate kill any chance of reform, but even if passed, it will not transform the health care system. "
....
"A “weak” public plan, as proposed by Len Nichols and John Bertko, would compete with private insurers by being transparent, nonprofit, and well-intentioned. It would follow all the rules required of private plans and not leverage Medicare’s buying power. Such a plan will need public funding to get started, probably bringing the public contracting, employment, and other rules that would hobble its ability to compete. An alternative to the “build your own” version is what many states have developed for their employees: a public plan that designs benefits and provider networks and carries risk, but leaves administration up to contractors."
....
"I propose an alternative avoiding the weaknesses of both the public solutions such as Medicare for all and current private insurance plans, while building on the strengths of each. It establishes a publicly chartered major risk pool that eliminates the need for the problematic behaviors of private health plans while enhancing choices for providers and patients.

"The new entity would be publicly chartered, but nongovernmental. Independence from direct
congressional oversight means that it avoids being hamstrung by special-interest groups. It has a publicly appointed board with long terms, similar to the Federal Reserve, with even higher expectations for transparency. Aside from some start-up funding, the pool is self-financing.

"The major risk pool would not itself offer coverage directly to consumers; instead, it would offer reinsurance for hospitalization and chronic care — the most expensive components of health care — to health plans, which would sell comprehensive wraparound packages. In my book, Total Cure: the Antidote to the Health Care Crisis, I use the term “Universal Coverage Pool,” or UCP to describe most of these functions. The plan for health reform called SecureChoice in Total Cure has income-based subsidies and other features that may or may not be included in the current legislative discussion. Here I use the term “major risk pool,” or MRP, to describe a more narrowly construed publicly chartered plan.

'The rationale for the MRP is twofold. (1) By pooling risk for the most expensive and financially threatening components of health care, it spreads risk broadly. Allowing health plans to buy coverage at demographically determined rates, it eliminates significant administrative and marketing expenses. (2) By paying in new ways for what covers, it will transform the delivery system."

I will admit that this is beyond my amateurish economic capabilities to evaluate well. So, I'll wait until Hacker or Nichols or others do, and keep you posted...

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McKinsey: What Matters: Way too much for way too little

McKinsey: What Matters: Way too much for way too little

The title says it all. A great review of the American health care non-system.

Goes over administrative waste (83 cents of premium dollars go to actual health care at most in PHI market), outcomes, costs and prices, administrative burden, practice variation, and rationing (QALY's CER).

Some good response letters as well.

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COST: Is This What They Went to Med School For? | New America Blogs

COST: Is This What They Went to Med School For? New America Blogs:

Excellent summary by Joanne Kenen at New America:

"Two new studies released this week online by Health Affairs examine how health care providers, particularly physician practices, interact with insurers. One study found that doctors personally spend the equivalent of three full weeks a year on billing and related insurance information. The overall cost to their practices (their time as well as other medical and clerical personnel) was about $31 billion a year (in 2006)—which as study author Larry Casalino noted, was about six times what we spent at the time on the State Children's Health Insurance Program and nearly 7 percent of total national expenses on physician and clinical services. Primary care practices spent more time on these administrative tasks than specialists. Very little of the data—only about two hours a year for the doctor—pertained to quality data.

"The second study looked at the billing and insurance-related activities at one large multi-site, multi-specialty California group practice. The cost (in physician and clerical time) turned out to be $85,276 per physician, or 10 percent of operating revenue. (And that excluded the time the doctors spent recording procedure and diagnosis codes). And this California practice isn't bogged down in paper; they already use electronic medical records for both clinical and billing data. (Some older studies, before medicine began its slow and not always so steady migration to Health IT, showed even more time and money spent on administration in the days of pure paper.)"

Additionally, from the second paper:

Impact of complexity. Previous reports have suggested that the complexity inherent in the current multipayer financing system is responsible for increasing the administrative burden associated with medical groups' transaction processing.15 During our interviews, informants frequently described the contributions of complexity in the payment system to billing and insurance burden. For example, the patient population of our study site is covered by hundreds of insurance plans, each with its own rules about benefits covered and under what conditions, payment rates, and often billing procedures. This complexity adds burden to billing and insurance tasks, including procedure coding, drug formulary authorizations, discussions with patients, submission and appeal processes, and receipt of payments. The complexity also increases the chance for error and dispute, increasing the likelihood of payment follow-up and collections. Even high-deductible plans, which might appear to avoid administrative burden for initial services during the year, impose billing/insurance costs because each service, including those within the patients' deductibles, must be evaluated and processed.

I've also classified this under Physician Income and Physician Autonomy, because these burdensome duties and their concomitant expenses impact both significantly. If you think your PHIs are paying you more than Medicare, you need to factor this into the equation.

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Letter - Schumer Health Care Plan - NYTimes.com

Letter - Schumer Health Care Plan - NYTimes.com:

"Re “Schumer Points to a Middle Ground on Government-Run Health Insurance” (news article, May 5):
There are a number of problems with Senator Charles E. Schumer’s so-called middle ground on universal health care. While your article acknowledges some of the structural ones — like whether a federal program could ever be subject to state laws — it doesn’t acknowledge the major issue: What is best for health care consumers?
What system is going to provide the best care? How can we provide meaningful health care to the greatest number of people with the resources available? What policies can we carry out now to ensure that there will be sufficient caregivers to meet our needs in the future?
These are the questions that we should be asking. As an advocate for consumers, I am distressed to see yet another health care discussion that focuses on the impact on insurance providers’ bottom line. The fundamental purpose of the health care system is to provide health care, not to protect and perpetuate an industry.
Richard Mollot
Executive Director, Long Term
Care Community Coalition
New York, May 5, 2009"

Well said. I was listening to a Center for American Progress Podcast of a talk given to them by Max Baucus, and I kept thinking, where is the vision? It was mostly about how we were stuck with working with our current system and tweaking it into some public-private amalgam that would be "uniquely American." This is disappointing in many ways, but I primarily am disappointed that he reflects that stubborn conservative world view that we cannot learn from other countries, that their experiences mean little or nothing to us. If you take that view, then transformational change is impossible to envision, and you are stuck with timid change.

But also troublesome is the complementary idea that America cannot do this, because we must think so timidly, in such limited ways. JFK said, "we choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too."

Where is THAT America, Senator Baucus, Senator Schumer?

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Letters - Going Dutch - NYTimes.com

Letters - Going Dutch - NYTimes.com:

I didn't post about the original article, it's in my stack of reading material, but i liked the letters, especially the first one here:

"To me as a religious-studies professor and Lutheran minister, the most telling line in Russell Shorto’s article (May 3) was, “This system developed not after Karl Marx, but after Martin Luther and Francis of Assisi.” The last time I taught in the Semester at Sea program, I found it necessary to interpret for our students the rich “social capital” that runs through the Northern European societies we were visiting. What they knew and had read in their guide books was that not many people are in church on Sunday morning, especially compared to the florid religiosity of the United States. So their working assumption was that Americans take religion seriously and Europeans don’t. The new thought that amazed them was that the unchurched Europeans live in social democracies deeply saturated with historic Christian values, while the much-churched Americans celebrate a society characterized by a ruthless social Darwinism that the God of the Bible, Old and New Testament alike, denounces.
DONALD HEINZ
Gig Harbor, Wash."

As to the rest of the letters, particularly the critical ones, I simply say, "OMG, you mean there are trade-offs required? We can't have everything for nothing? Then count me out!"

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Health at a glance: OECD indicators 2005 - Google Book Search

Health at a glance: OECD indicators 2005 - Google Book Search

I was looking to find the prevelance of Nurse Practitioners elsewhere in the world and found the entire OECD "Health at a glance 2005"

Very interesting.

Who has the highest paid specialists? The Netherlands.

Where do PCPs and specialists get paid the same? Portugal.

Most MRIs? Japan. CTs? Japan.

And who pays the most? Oh, you know this one!

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What Is ‘Socialized Medicine’?: A Taxonomy of Health Care Systems - Economix Blog - NYTimes.com

What Is ‘Socialized Medicine’?: A Taxonomy of Health Care Systems - Economix Blog - NYTimes.com:

"Socialized medicine refers to health system in which the government owns and operates both the financing of health care and its delivery. Cell A in the chart represents socialized medicine.

"Social health insurance, on the other hand, refers to systems in which individuals transfer their financial risk of medical bills to a risk pool to which, as individuals, they contribute taxes or premiums based primarily on ability to pay, rather than on how healthy or sick they are."
...........
"Former Mayor Rudolph Giuliani of New York has exemplified the perennial confusion in this country over socialized medicine. In his ill-fated presidential bid, and subsequently as a supporter of Senator John McCain’s bid for the presidency, Mr. Giuliani routinely decried as socialized medicine (or “socialist”) any proposal presented by Democratic candidates, because typically the latter advocated tax-financed subsidies toward the purchase of health private insurance or expansions of public insurance programs. But technically none of them advocated socialized medicine.

"Perhaps Mr. Giuliani was unaware that Americans all along the ideological spectrum reserve the purest form of socialized medicine — the V.A. health system — for the nation’s veterans. I find this cognitive dissonance amusing. Indeed, if socialized medicine is so evil, why didn’t Republicans privatize the V.A. health system when they controlled both the White House and the Congress during 2001-06?

"Mr. Giuliani also seems to forget that, in 1996, he found social health insurance a perfect solution to the financial problems faced by former Mayor John V. Lindsay, who fell on financially hard times during the 1990s as a result of chronic illness. "

The chart in the piece is a little tough, the text is better, specifically the first two paragraphs above.

But to me, the key is do we want to continue to decide who can get health care and health insurance based upon their luck? And I don't mean luck in being financially successful, I mean luck in not getting a chronic, life threatening, debilitating illness. And if we get lucky, and make it to Medicare without a big illness, do we really want to rely on that luck holding out for our children, our nieces and nephews, our grandchildren? I don't.

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Uwe Reinhardt: A Medicare-Like Plan for the Non-Elderly - Economix Blog - NYTimes.com

A Medicare-Like Plan for the Non-Elderly - Economix Blog - NYTimes.com:

"A public health plan, however, strikes fear in the hearts of many interest groups. There are several reasons for this.

"First, it is only human that the politically powerful private health-insurance industry opposes competition from such a plan. The industry argues, not without justification, that a public plan might be advantaged by dictating to providers lower prices for health care services and products, and it might benefit from hidden subsidies. That unfair advantage could squish the private plans to the wall.

"But even if those comparative advantages could be eliminated through careful design of the public plan, the industry probably fears the inherent appeal that a public plan might have among the American people.

"The providers of health care and health care products, to whom “national health care spending” represents “national health care incomes,” fear the market power that a public health plan might bring to the demand (payment) side of the health sector.

"Greater market moxie on the demand side, they fear, might significantly bend down the lush, currently projected, long-run growth path of America’s health spending, which has national health spending rise from the current 16.6 percent of gross domestic product to 20.3 percent by 2018 and to 38 percent of G.D.P. by 2050. Once again, it is only human that the supply side of the United States health system prefers a continuance of the weaker, more fragmented demand (payment) side that for four decades now has allowed health spending to grow in excess of 2 percentage points faster than the rest of the G.D.P.

"The most powerful ordnance lobbed at the public health plan by its opponents is the dreaded “R” word, that is, the prediction that it will lead to the rationing of health care in America. In the debate on health policy, getting slapped with the R-word has always has been the kiss of death for any proposal.

"Evidently, many Americans do sincerely believe that when a public health plan refuses to pay for a procedure it is “rationing,” while denial of health care to an uninsured, low-income individual who cannot afford to pay for that care is not. But as textbooks in economics explicitly teach, the role of prices in a market economy is precisely to ration scarce resources among unlimited demands.

"The American health system has rationed health care by price and ability to pay all along for a sizeable segment of the United States population. In its report “ Hidden Cost, Value Lost,” for example, a distinguished panel of experts convened by the Institute of Medicine of the National Academy of Sciences estimated that some 18,000 Americans die prematurely for want of health insurance and timely medical care. That is rationing life years."

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Public Opinion on Health Policy

Health Policy Public Opinion Data Aggregation: h/t to Blue Texan at FDL for pointing me to this, thanks to www.pollingreport.com for putting it together!

CNN/Opinion Research Corporation Poll.
Feb. 18-19, 2009. N=1,046 adults nationwide. MoE ± 3

"In general, would you favor or oppose a program that would increase the federal government's influence over the country's health care system in an attempt to lower costs and provide health care coverage to more Americans?"

	Favor	Oppose	Unsure
2/18-19/09	72%	27%	1%

CBS News/New York Times Poll
Jan. 11-15, 2009. N=1,112 adults nationwide. MoE ± 3

"Should the government in Washington provide national health insurance, or is this something that should be left only to private enterprise?"

	Government	Private Enterprise	Unsure
1/11-15/09	59%	32%	9%
1/79	40%	48%	12%

Quinnipiac University Poll.
Nov. 6-10, 2008. N=2,210 registered voters nationwide. MoE ± 2.1 (for all registered voters).

"Do you think it's the government's responsibility to make sure that everyone in the United States has adequate health care, or don't you think so?"

	Think It Is	Don't Think So	Unsure
11/6-10/08	60%	36%	4%
Republicans	34%	63%	3%
Democrats	84%	12%	4%
Independents	56%	39%	5%
5/8-12/08	61%	35%	4%
10/23-29/07	57%	38%	5%
2/13-19/07	64%	31%	4%

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Foregoing care due to cost | New America Blogs

HEALTH CARE: If This Is An Emergency, Please Press "Can't Afford It" New America Blogs:

From the New America Healthcare Blog ...

"Imagine being sick enough or hurt enough to rush to an emergency room—and then leaving without getting the recommended tests or treatment because you can't afford it.

"Doctors have a name for those discharges—'Against Medical Advice.' It seems to be happening more often, both in the ER and in the rest of the hospital as health costs rise and insurance coverage falls.

"MSNBC interviewed several doctors and patients about how the economy is affecting emergency care. A patient with acute appendicitis needing emergency surgery who waited for his mother to drive him to the hospital so he wouldn't have to pay for an ambulance. A patient with an infected kidney stone. People with chest pains who were not in the throes of a life-threatening heart attack that very minute but who couldn't or wouldn't follow up to find out what the pains signaled. A 31 year old knocked unconscious in a bike crash, who asked about the cost of the recommended follow up, only to be told by the ER doctor, that she was 'a physician, not an accountant.' Declining treatment, he still got a $600 bill."

There's more at New America and at MSNBC...

I would only add this, from a wise NY Times reader:

Mr. Krugman rightly notes that emergency room care cannot substitute for health insurance since the cost will be billed directly to the patient.

There is another reason emergency rooms cannot provide adequate health care. Emergency rooms are for emergencies. They can treat a patient in a diabetic coma, but they cannot provide continuing help in managing diabetes. They can treat a full-blown asthma attack, but they cannot provide the medications needed to manage asthma daily.

They can treat a woman who has gone into early labor, but they cannot provide prenatal care.Emergency rooms cannot offer any help for managing Parkinson’s, Alzheimer’s or cancer. On a more basic level, they cannot provide eyeglasses, hearing aids or dentures.

Republican claims that no American is without access to health care because “you can just go to an emergency room” are openly false as well as appallingly callous.

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Health Affairs Blog Lessons Of Medicare For The New Public Health Insurance Plan

Health Affairs Blog: Lessons Of Medicare For The New Public Health Insurance Plan:

"As Congress grapples with whether a new public health insurance plan should be created as part of health care reform, they should take stock of the nation’s experience with Medicare as a public program. Medicare’s strengths and limitations offer a number of lessons for the current debate."

A nice summary of what is right about Medicare, as well as what to avoid (i.e., Medicaid) as we develop a Public Plan. Quick summary:

1. Medicare is stable and secure. Medicaid is subject to the whims of state governments and is therefore neither.

2. Medicare is nationally uniform, Medicaid, not so much. In fact Medicaid is pretty awful for uniformity and results in rationing of health care in many parts of the country.

3. Transparent and consistent, resulting in lower administration costs, and more predictability for all. But, they argue, and I agree, that congress should not be making the detailed coverage decisions. these should be delegated to an independant board.

4. Provide innovation and leadership in payment reform.

5. Minimizes administrative costs in a variety of ways. I know I can't watch a sporting event, television program or anything without seeing my "not-for-profit" insurance company logo all over the place.

6. Public accountability. I always am disbelieving when i hear my conservative friends talk about governement as if it is not us. I reject this, because when we participate, it does work. Of course, the last eight years showed us that the trolley can go off the rails, but we eventually correct.

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Luntz to GOP: Health reform is popular - Politico.com Print View

Luntz to GOP: Health reform is popular - Politico.com Print View: "Luntz’s 10 pointers in “The Language of Healthcare 2009”:

(1) Humanize your approach. Abandon and exile ALL references to the “healthcare system.” From now on, healthcare is about people. Before you speak, think of the three components of tone that matter most: Individualize. Personalize. Humanize."

You know, pretend to be human, to care, to have a soul, and all that liberal sissy stuff.

There's lots more from the master of manipulative language...

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Senate Finance Committee Hearing on Expanding Health Care Coverage

"Roundtable Discussion on “Expanding Health Care Coverage”
May 5 , 2009, at 10:00 a.m., in 106 Dirksen Senate Office Building

Over at the PNHP Blog, Don McCanne points out that the voices for single payer are being stifled and excluded because of the view of most in the Congress that it is a politically unviable proposition, though he "respects" their views.

Even more problematic was an exchange later in the hearings between Sen. Pat Roberts and Scott Serota, CEO of the Blue Cross and Blue Shield Association.

Sen. Roberts told the tale of how a group of surgeons and anesthesiologists surrounded him after his knee surgery and told him and said they'd all quit if we went to a national health plan or even, I believe, to a public option and their reimbursements were to be decreased.

I don't have the transcript, but he went on to say something along the lines of how there was no way to control costs in a national health system and then asked Serota what he thought.

Of course, Serota explained in that patrician way of so many how there was no way in the world to produce high quality and lower costs than we have in the US now with private insurance.

Now, if Sen. Baucus doesn't want single payer advocates around because he doesn't think it is politically viable, that is one thing. But what he doesn't seem to realize is that having a knowledgeable single payer advocate and someone knowledgeable about international comparative health care in the room would have resulted in the particular line of BS that Roberts and Serota were peddling to be swatted down without breaking a sweat.

That is why it is so critical to have a broader range of views at the table. There was no one there willing to point out the obvious: Reducing future surgeons' income from $500 K to $400 K, for example, will not bring the world to a halt. Essentially every country in the world controls costs and maintains quality at massive savings compared to the disastrously inefficient US private insurance industry.

But there was no one at the table willing to tell them that.

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Schumer Offers Middle Ground on Health Care - NYTimes.com

Schumer Offers Middle Ground on Health Care - NYTimes.com:

"Scorched by Republican opposition to the idea of a new public program like Medicare, Senate Democrats are looking for a middle ground that would address the concerns of political moderates. One way they propose to do that is by requiring the public plan to resemble private insurance as much as possible.

“The public plan,” Mr. Schumer said Monday, “must be subject to the same regulations and requirements as all other plans” in the insurance market. Democrats in Congress hope to shift the debate from the question of whether to create a public health insurance plan to the question of how it would work. In so doing, they look for the support of influential moderates. But in the last few days, three moderate senators — Ben Nelson, Democrat of Nebraska; Olympia J. Snowe, Republican of Maine; and Arlen Specter of Pennsylvania, who switched parties to become a Democrat — have expressed reservations about a public plan.

Insurers also remain skeptical. Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group, said, “We are very, very grateful that members of ongress have been thoughtfully looking at our concerns.” But she said she still saw no need for a public plan “if you have much more aggressive regulation of insurance,” which the industry has agreed to support.

Linda Douglass, a White House spokeswoman, said that Mr. Obama was for a public plan but that he realized it could be defined in different ways. Mr. Schumer said his goal was “a level playing field for competition” between public and private insurers.

But Ms. Ignagni said, “It’s almost impossible to accomplish that objective.”"

...with high corporate salaries, really nice corner offices, expensive buildings, luxury sports boxes and all those other bare necessitites of modern corporate life!

Firedoglake also has a good post on this as a capitulation.

And Rachel Maddow reported tonight about White House talked about offering some concessions in the HC reform debate and that, in return, the Republicans offered (wait for it!) nothing!

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OECD Waiting Times Study Executive Summary

I realized that while I have a link to this study elsewhere, it is rather a pain to get to the information because the document is in pdf.

Now, this is from 2003, and so the UK/NHS data is now happily out of date. And leaders in Canada have seen the results in the UK and are pushing to end the bloc financing of hospitals that helped so much in the UK. But anyway, here is the summary:

• Waiting times for elective surgery are a significant health policy concern in approximately half of all OECD countries.
• This report is devoted to [analyzing waiting times]. An interesting feature of OECD countries is that while some countries report significant waiting, others do not.
• Waiting times are a serious health policy issue in the 12 countries involved in this project (Australia, Canada, Denmark, Finland, Ireland, Italy, Netherlands, New Zealand, Norway, Spain, Sweden, and the United Kingdom).
• Waiting times are not recorded administratively in a second group of countries (Austria, Belgium, France, Germany, Japan, Luxembourg, Switzerland, and the United States) but are anecdotally (informally) reported to be low.
  
• This paper contains a comparative analysis of these two groups of countries and addresses what factors may explain the absence of waiting times in the second group. It suggests that there is a clear negative association between waiting times and capacity, either measured in terms of number of beds or number of practising physicians. Analogously, a higher level of health spending is also systematically associated with lower waiting times, all other things equal.
  
• Among the group of countries with waiting times, it is the availability of doctors that has the most significant negative association with waiting times. Econometric estimates suggest that a marginal increase of 0.1 practising physicians and specialists (per 1 000 population) is associated respectively with a marginal reduction of mean waiting times of 8.3 and 6.4 days (at the sample mean) and a marginal reduction of median waiting times of 7.6 and 8.9 days, across all procedures included in the study.
  
• Analogously, an increase in total health expenditure per capita of $100 is associated with a reduction of mean waiting times of 6.6 days and of median waiting times of 6.1 days.
  
• In the comparison between countries with and without waiting times, low availability of acute care beds is significantly associated with the presence of waiting times. Also, evidence from this and other studies suggests that fee-for-service remuneration for specialists, as opposed to salaried remuneration, is negatively associated with the presence of waiting times. Fee-for-service systems may induce specialists to increase productivity and may also discourage the formation of visible queues because of competitive pressures. In addition, evidence from this and other studies suggests that activity-based funding for hospitals may also help reduce waiting times.

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Exclusive: NHS hospital waiting times are the lowest since records began - mirror.co.uk

Exclusive: NHS hospital waiting times are the lowest since records began - mirror.co.uk:

"Hospital waiting times are the lowest since records began, Health Secretary Alan Johnson will say today as he rounds on critics of the NHS.

"Mr Johnson aims to hit back at the doom and gloom-mongers by showing how the nation's health service has been transformed for the better in the 12 years since 1997.

"He will highlight figures showing delays for treatment have fallen in many areas."

Some of the numbers are quite impressive. I don't think these numbers are significantly different than US (and by that, I mean these are not intolerable waits by most standards). And remember, they hae health care for their entire population, not just those who can afford it.

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Kaiser Family Foundation Health Policy Tutorials and Compendia

Tutorials:

KaiserEDU's tutorials are multimedia presentations on health policy issues, research methodology or the workings of government.

Here are a few to get started (I haven't yet, but put them here for reference and eventual use!)

Health policy experts provide overviews of current topics in health policy. Watch and download slides from these and other tutorials:
The Public and Health Care Reform
A Primer on Tax Subsides for Health Care
Expanding Health Coverage to the Uninsured

They also have Compendiums:

These modules include background summaries along with links to academic literature, policy research and data sets on current health policy issues, such as:
U.S. Health Care Costs
Health Information Technology
Addressing the Nursing Shortage
The Uninsured
International Health Systems

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