Monday, December 29, 2008

Reece, personal musings - No Silver Bullets for Health Reform

There are no one, two, or even ten silver bullets. Controlling costs will be very difficult.

Robert Laszewski, Inside-Beltway Consultant, “Naïve Policymakers Need Not Apply,” The Health Care Blog, December 24, 2008

I: Why are you interviewing yourself?
Me: This is my blog, and I will interview whom I please. You might say it’s an I for I, and a truth for a truth. I see I to I, you see, with me.

I: Get serious. What’s this self-imposed blog about?
Me: It’s a history lesson. There’s no mystery to history. It’s the present and future that’s obscure.

When Medicare and Medicaid passed in 1965-1966, the Johnson Administration assured us the combined programs’ cost wouldn’t exceed $9 billion. Now, 43 years later, the cost is approaching $1 trillion, may double in five more years , and threatens to bankrupt the government.

I: What’s the lesson?
Me: There are four lessons.

• One, if you think health care is expensive now, just wait until we have “free” government care. Anytime you have a government program, people will find a way to “game” the system, driving up costs. The government will have to decide selectively what it can pay for, not how it can pay for everything.

• Two, when you expand coverage, you invariably spend more money. As sure as dawn follows darkness, expanded government care will drain the federal treasury.

• Three, money, even federal money, isn’t unlimited with the current budget deficit of $2 trillion or so. No tree, no fee, grows to the sky. There’s no free lunch and no free for service, if you’ll pardon a cliché couplet.

I: Why not pardon you ? It hasn’t stopped you before.
Me: Back to the history lesson.

• Four, complexity science and chaos theory is at work. A butterfly flapping its wings in Brazil can cause a tornado in Texas and 5% of foreclosed mortgages in California can bring down Wall Street. The same forces may be at work in health care.

I: Do I detect a note of cynicism?
Me. No, what you detect is realism based on experience. The only long term solution is to make people pay something out of pocket for health care, with a cap of unaffordable catastrophic care and with unspent tax-free money set aside for retirement. But that will not happen in a society like ours that is afflicted with the entitlement syndrome.

I: So what now?
Me: So universal coverage will become a matter not only or morality but of economics. Take Massachusetts, if you please. Two years after its inception, the Massachusetts universal coverage plan is driving costs out of sight in the second most affluent state in the union and one with one of the lowest rate of uninsured. If it doesn’t work in blue heaven under ideal conditions – affluence, a 10% rate of uninsured, and a liberal culture – will it work in Texas, California, and Florida – with populations of without health insurance estimated at these levels - Texas 24%, California 19%, and Florida 21%

I: So what, if universal coverage is the right thing to do?
Me: Universal health coverage may be the right thing to do, but what good is it if there isn’t any access to primary care doctors – the case in Massachusetts. Universal insurance isn’t the same as universal access. One without the other is meaningless.

I: Look, we can solve the primary care problem by paying primary care doctors more, making primary care doctors debt free by making medical school free for future primary care doctors, erasing the income differences between primary care and specialty doctors.
Me: You are blissfully naïve. According to a recent 400 page report by the Congressional Budget (CBO), we’ll have to attack the following structural problems of U.S care simultaneously and in no particular order for comprehensive reform.

• Change the health insurance system, partly by making health plans offer premiums with pre-existing illness, punishing those profitable HMOs and PPOs and powerful lobbyists , especially those who profit from Medicare drug plans and hundreds of thousands of employees.

• Reform medical malpractice, fat chance with Congress being 70% lawyers.


• Radically alter the tax system, by removing tax-free incentives for corporations and giving it to individuals and small businesses.

• Compelling big business to “pay or play,” meaning fining them is they don’t cover employees, One wonders how this will play politically in a deep recession with big employers already stretched thin and laying off hundreds of thousands of workers.


• Expand access to public programs.

• Incentivize innovations from the private sector without stifling them with foolish regulations.


• Reward health care performers and punish non-compliers, by documenting every health care encounter without creating the illusion that documenting is more important than doctoring.

• Require EMRs for hospitals and doctors and other “providers, to participate in Medicare, even if EMRs cost too much, drive down productivity, have not been shown to cut costs or improve quality.

• Force hospitals and doctors to bundle payments as one entity.

• Insure all children, a no-brainer even for those with no heart.

• Herd those 85% of doctors who now practice independently into multispecialty group practices, put them all on salary, and reduce spending by 30% (Alain Enthoven, “Health Care with a Few Bucks Left ovewr,” New York Times, December 28, 2008).

I: You don’t have to document what you say. I trust you. If you can’t trust me, who can you trust?
Me: Nobody.So I’ll go on.

• Restructure primary care by having doctors serve as directors of medical homes that offer coordinated comprehensive and preventive care.

• Institute cost sharing among hospitals and doctors who perform well and save money..


• Punish fraud and abuse, an inevitable temptation when you’re dealing with federal monies spilling off government printing presses.

• Save and share money from nursing homes, laboratories, and imaging technologies.


• Make having an EMR a condition for participating in Medicare.

• Create a federal technological institute for judging the effectiveness and outcomes of different modes of care.


• And of course, MDR (Mandate, Document, and Regulate) until the cows come home. You can’t trust anyone outside the sacred halls of government.

I: You’re talking about the future. I thought this was going to be a history lesson.
Me: The history lesson is that our health system is a creature of our democratic culture. As a people we desire open-ended access access to the best specialists, latest, and mostl costly technologies, treasure our freedom to choose the specialists of our choice, avoid high taxes for the general social welfare, are leery of big government, and, of course, want someone else pay for it all.

I: Please give me historical examples of what led us to this point, and what makes reform impossible.
Me: I never said reform was impossible, I said “sweeping reform” was difficult. To understand why, I recommend the following readings.

The Social Transformation of American Medicine, by Paul Starr, 1982. Starr described how American taxpayers rewarded the health care establishment after World War II though the Hill-Burton Act of 1946, funding the National Institutes of Health, and pouring money into research and new technologies, mostly created by big institutions and deployed by specialists.

And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota, 1988, by yours truly. As the title implies, I thought managed care would scare off many doctors and leave too few care to care for the sick, and I believed corporations, with HMOs as their surrogates, would transform medicine. As it turned out, managed care failed, retrained costs only temporarily, and drove primary care into the ground.


• The Road to Reform; The Future of Health Care in America, 1994. An instructive text by Eli Ginzberg a noted health reformer, economist, and critic leading us through the maze of complex forces and special interests that make up health care. The book was a prelude to the smashing crash and burning of health care reform as conceived by the Clintons.

The overall history lesson here is: It’s our culture, Stupid! It may be naïve, it may be overly optimistic, it may depend too much on others paying the bill, but it’s our culture.

I: Is there any way to fix the system?
Me: Sure, but it’s going to incremental, it’s going to be painful, it’s going to be by trial and error, it’s going to be the testing and rejection of entrepreneurial innovations, and it’s going to be through an uneasy symbiosis between government and business, with business leading the way in many instances, because its survival is at stake in the global economy and because business can move quickly and decisively. The prospect of bankruptcy in the morning concentrates one’s attention.

I: What about doctors?
Me: Right now doctors are a discouraged, demoralized, and desultory bunch, looking for leadership, in a profession divided into 190 different specialties. But there is a shortage of ud , thanks to government and managed care policies and third parties in general and underestimates of opultion growth. We are in demand, we are mobilizing, and we are asking for a seat at the health reform table. We have leverage because you can’t run the system without us. I think we will respond to the challenges put before us, we will remain the backbone of the delivery system, and we’re fully aware we need the help of physician assistants, nurse practitioners , and all the other physician extenders to make things work. No physician is an island in this complex health care world.

I: So what will an Obama administration do?
Me: The Obama administration will quickly pass universal coverage for kids and fund stem cell research. From there on, it will be uphill, one battle at a time. Health care for all children and money for stem cell research are “feel good” programs, and I endorse them, but they don’t have any real economic consequences in the overall scheme of things.

I applaud Obama’s pragmatic tone, his sense of what’s possible, and his promises of hope. But given the $2 billion deficit, I wonder what is possible without raising taxes. The “rich,” those making over $250,000, are rapidly shrinking as the sole sugar daddies and the soul source capable of financing health care for all. The tax dollars are where they’ve always been – in the middle class. And I frankly don’t see how we can save enough money through EMRs, prevention, and chronic disease management to make a go at universal coverage soon.

4 comments:

Anonymous said...

I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.


Susan

http://www.car-insurance-choices.com

Richard L. Reece, MD said...

Thansks, Susan. Have a splendid new year, and make the right health care choices. RReecde

Dan said...

A Need To Reformulate

The following are facts that are believed to exist regarding the present U.S. Health Care System. This may be why about 80 percent of U.S. citizens understandably want our health care system overhauled:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
However, the U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care costs are now well over 2 trillion dollars of our gross domestic product. This is three times the amount nearly 20 years ago- and 8 times the amount it was about 30 years ago. Most is spent with medical institutions, as far as health expenditures are concerned. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which may cause about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children, which alone covers about 7 million kids.
Our children.
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage is largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits to a damaging degree.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA, according to others.
Our health care we offer citizens is the present system is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Health Care must be the priority immediately by the new administration and congress. Challenges include the 700 billion dollars that have been pledged with the financial bailout that will occur, since the proposed health care plan of the next administration is projected to cost over a trillion dollars within the first year or so of the proposed plan to recalibrate health care for all of us in the U.S. Yet considering the hundreds of billions of dollars that are speculated to be saved with a reform of the country’s health care system, health policy analysts should not be greatly concerned on the steakholders who may be affected by this reform of our health care system that is desperately needed. Tom Daschle leads this Transition’s Health Policy Team. And we also have Ed Kennedy, the committee chair and a prolific legislator. So if the right people have been selected for this reforming team, the urgency and priority regarding our nation’s health care needs should be rather overt to the country’s citizens.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported, which should be addressed as well.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. This specialty makes nearly 100 thousand less in income compared with other physician specialties, yet they are and have been the backbone of the U.S. health care system. PCPs manage the chronically ill patients, who would benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly have of the population has at least one chronic illness- with many of those having more than one of these types of illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget.
The shortage of primary care physicians is due to numerous variables, such as administrative hassles that are quite vexing for these doctors, along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients. Many PCPs are retiring early, and most medical school graduates do not strive to become this specialty for obvious reasons. In fact, the number entering family practice residencies has decreased by half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers.
Yet if primary care physicians were increased in number with the populations they serve and are dedicated to their welfare. Studies have shown that mortality rates would decrease due to increased patient outcomes if this increase were to occur. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if they are numbered correctly to treat and restore others. Also, the quality improves, as well as the outcomes for their patients. Most importantly, the quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase in the years to come. The American College of Physicians believes that a patient centered national health care workforce policy is needed to address these issues that would ideally restructure the payment policies that exist presently with primary care physicians.
Further vexing is that it is quite apparent that we have some greedy health care corporations that take advantage of our health care system. Over a billion dollars was recovered for Medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations who deliberately ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy, so it seems.
Health 2.0, a new healthcare social networking innovation, is informing patients about their symptoms and potential if not possessing various disease states- largely based on the testimonies of other people on various websites. This may be an example of how so many others rely now on health concerns from those who likely are not medical specialists, instead of becoming a participant, if not victim, of the U.S. Health Care System.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up this system as it exists today, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens, it appears. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals, potentially. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in as it is designed at this time- as it exists today.
http://www.mckinsey.com/mgi/publications/US_healthcare/index.asp
Dan Abshear

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