Monday, June 22, 2009

Untold stories - Ten Untold Stories about Health Reform

Untold Story One – A nation’s health system accounts for only about 15% of a nation’s health status, life style makes for 30% and other factors – poverty, inferior education, income differences, and lack of social cohesion make up the other 55%(Satcher, D, and Pamies, R (2006), Multicultural Medicine and Health Differences, McGraw Hill). Therefore, any reform of our system is unlikely to increase the nation’s overall health status. In other words, a nation’s culture and its life style habits determines its health

Untold Story Two - You can make polls about health reform mean anything you want them to mean. A survey of 895 Americans found 72% supported a government-run plan, but 67% felt such a plan would decrease costs and restrict choice of doctor (“In Poll, Wide Support for Government-Run Health, New York Times, June 20, 2009). Don’t trust the headline spin, i.e., “Wide Support for Government-Run Health,” until you look carefully at the “internals” of the poll. The truth is, 80% of insured Americans are skeptical of a government takeover for fear they will lose their existing policies.

Untold Story Three – The “uninsured” population is believed to be mostly poor and sick. In reality, 1/2 are employed, 2/3 to ¾ are in good health. Many are “young invincibles” on good health, who use their money for other things. About ½ are between jobs, 1/5 are not citizens, ¼ are eligible for government programs, and 1/5 have household incomes over more thatn $75.000. Finally, Obama’s plan would cover only 16 million of the 46 million at an estimated cost of $1.6 trillion. The public is beginning to ask: is is worth covering the uninsured if the consequence is a huge addition to the national debt? One ironic twist: all health care stakeholders support covering the uninsured because universal coverage assures payment for another 46 million people.

Untold Story Four – Medicare “administrative costs” are low, about 3% of costs, much lower than private plans, but the reasons why are not administrative “efficiency,” but because Medicare subcontracts administrative tasks, has not market expenses, does not have to negotiate contracts, has no competition, and runs no business risks because it has government dollars to back whatever they do. Furthermore, Medicare can charge whatever it wants to charge – without fear of market backlash or losing customers.

Untold Story Five - Medicare underpays hospitals and doctors by $90 billion each year and shifts costs to the private sector. These differences would have to be made up with a government-plan. Because more and more doctors, perhaps 30% are not accepting new Medicare patients and more than 50% will not see new Medicaid patients; because of an increasing primary care shortage; because of the recession, which produces more Medicaid applicants; and because 78 million baby boomers will start turning 65 in 2011, the next big political crisis will be lack of access to doctors.

Untold Story Six - Government reimbursement of new programs for prevention are more likely to produce expensive programs for prevention costing billions of dollars rather than to save money. Here is how Abraham Verghese, MD, a professor of medicine at Stanford, views the situation, “Keep in mind that you may have to treat several hundred people to prevent one heart attack. Using a statin costs about $150,000 for every year of life it saves in men, and even more in women (since their heart-attack risk is lower)—I don’t see the savings there. Or take the coronary calcium scans or heart scan. It’s a money maker, without any doubt, and some institutions actually advertise on billboards or in newspapers.

Untold Story Seven - Widespread use of medical records may not save money, but instead will result in the so-called “iPatient syndrome. “ Doctors spend more time entering information, reading glowing computer screens, and making sure the record is complete than listening to patients. examining them, holding their hands, or counseling them . Of the iPatient phenomenon, Verghese comments, “Electronic medical record (EMR) may or may not save money (it won’t be anywhere as much as is projected) but what it will do is ensure that we doctors, nurses, therapists, particularly in hospitals will be spending more and more time focused on the computer, communicating with each other, ordering and getting tests, buffing and caring for our virtual patient - while the patient in the bed wonders where everybody is. “ Treating the medical record is not the same as treating the patient.

Untold Story Eight - Those who espouse government care believe in mass uniformity is more important than individual choice. Uniforming marks a profound philosophical difference between the “statists,” those who preach the gospel of equity and equality for all as enforced by government, and conservatives who advocate market improvisation and individual choice depending on the circumstances of patient-doctor interaction. Here is how Mark R. Levin, author of Liberty and Tyranny: A Conservative Manifesto, a book which has been number one the New York Times best seller list for the last 10 consecutive weeks, describes the situation, “The Statist misuses equality to pursue uniform economic and social outcomes. The Statists must claim the power to that which is unequal equal and that which is imperfect perfect.” An example is the current debates over practice variation among Medicare recipients. The government says such variations are “unwarranted” and insist they may be made equal, while the conservative argues socioeconomic conditions and costs of doing business are inherent unequal and to try to make them equal will violate individual liberties and choices.

Untold Story Nine - A rising number of policy wonks insist the only way to rationalize care is through organizing doctors into large groups, paying them on salary rather than fee-for-service, and reimbursing them on the basis of data-measured performance, population outcomes, episodes of care, management of patient panels, and continuous improvement of care that is integrated, coordinated, and comprehensive, all tracked by interlocking communicating interoperate medical records. This is “systems engineering” at work, and large multispecialty groups like Kaiser, Geisinger, Group Health Cooperative, have shown that it works for their patient populations. What is not said is that systems engineering requires a very expensive infrastructure and runs again the grain of most physicians, who prefer autonomy and who resist top-down control – by government and even their own leaders.

Untold Story Ten
- There are basically three ways to control cost – rationing by government of Medicare and Medicaid and the private sector, which is anathema to Americans; “savings” through as yet unproven national programs to prevent common chronic disease, information technologies to enforce compliance and demonstrate best practices; and market-driven innovations that rely on consumers spending their “own” money and taking responsibility for their own care by not becoming obese, eating right, exercising, and being rewarded for keeping their blood pressure and cholesterol levels and weight down. There are cost-reducing success stories out there among corporations, like Safeway and Toyota, and others who engage employees by strategies such as paying ½ their premiums for high deductible plans, encouraging purchases of health savings accounts, giving patients $1000 up front to spend for health care, instituting wellness programs, and establishing worksite clinics on site. But when the focus is on government control, as it is in the current Democratic-dominated Congress, you rarely hear anything about constructive roles for business. Instead the focus is on forcing business to pay for employee health care or pay a fine.

Last Friday's Wall Street Journal featured an opinion piece called How Safeway is Cutting Healthcare Costs, by Steve Burd, CEO of Safeway. Burd has long been an advocate of market-based solutions for the nation's health crisis, and he summed up the problem in simple terms:

"Safeway's plan capitalizes on two key insights gained in 2005. The first is that 70% of all health-care costs are the direct result of behavior. The second insight, which is well understood by the providers of health care, is that 74% of all costs are confined to four chronic conditions (cardiovascular disease,cancer, diabetes, and obesity.”

2 comments:

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