Thursday, April 14, 2016

Forty Years of Writing about  Health Reform
I started writing about health reform 40 years ago.   In 1976, as editor of Minnesota Medicine, I was in Boston taking an 8 week health management course, funded by the government,  backed by  Senator Edward Kennedy,  and conducted by the Harvard Business School,  the Harvard School of Public Health, and the Harvard Business School.   You might say it was an all Harvard health care show. In 2011 in my book The Health Care Maze,  I elaborated on the Harvard  phenomenon in a chapter  entitled  “Harvard-Driven Health Care."
Idea behind  Harvard Course
The idea behind the course was “… to enhance the skills and broaden the perspective  of senior health professionals."   Sixty percent of the 52  attending the course were physicians. I was the sole active practitioner.  The others were physician executives or administrators.     

The hidden agenda  of the course was to give Harvard’s perspective on  a national  universal health system, which seemed imminent at the time. So believed  most of our Harvard instructors.
Issues addressed in the course were:  how to control health costs, which were then $130 billion,  up 10% to 15% per year from $40 billion in 1965 when Medicare and Medicaid passed;   how to regulate  and manage doctors, who were thought to be driving up costs for personal profit;  and how to contain the use of technologies , such as CT scans,  of which there were 140 with a yearly operating cost of $500,000 each,  and coronary bypass surgery, with a per case cost of $10,000.  Our  teachers told us the outcomes of these things ought to be measured  by  their impact of outcomes in the general population before they were adopted for general use.
The  differences between 1976 and 2016,  are the explosive costs of new technologies like imaging,  heart procedures,  hip and knee replacements,   and the expenses of diagnosing and treating an aging population  with chronic diseases and multiple co-morbidities.     It is estimated, for example, that diabetes with its associated conditions takes 1 of every 3 Medicare dollars,  and that people signing up for ObamaCare health subsidies  have a 94% higher  rate of diabetes than the general population.
The principle difference from the system viewpoint, of course, has been ObamaCare, which passed in  March 2010. 
Has the health law made a difference?
Yes, for the uninsured. It has  reduced their numbers from 50 million to 30 million. And it  has subsidized their care on the health exchanges and Medicaid.  But in so doing,  it has increased premiums and deductibles,  often to unaffordable levels  for the middle class.
No, if you use cost control as a measuring stick. National health  costs since 1976 have escalated from $130 billion  to $3 trillion, and from 10% to 18% of GDP.   The Obama promises of a lower premiums of $2500 for a family and keeping your doctor and your health plan have not been fulfilled.   Many Americans now find even routine care unaffordable because of premium rises of 10% to 50% and deductibles of $1000 or more.   And, because of widespread primary care shortages,  many other consumers  cannot find a doctor to take care of them.
During the 1976 Harvard  course,  I fired off three editorials.
1)      The View from Boston- Part I   The essence of this editorial was not to worry.    It may take 3 to 5 years, but a national health plan will come with good management and a quasi-socialistic expertly managed system. 

2)     Medicine in Transition – Part II    In this editorial,  I  said Medicine is changing with more regulations,  more cost controls, more HMOs,  more group practices, and more physician assistants, and more power of hospitals and insurers and government over doctors. 

3)     Medical Leadership and Social Responsibility – Part III. Here I  said doctors had to take the lead and to recognize that  medicine has become a big business,  employing 4 million and taking 10%  of GDP.   Today those numbers are 12 million and 18% of GDP.   Physicians had to  master management skills, innovate, and join together to lower costs while increasing outcomes and patient satisfaction.
With the failure of ObamaCare to deliver on its promises of lowering costs, expanding choice,  and improving access,  physicians are responding.      They have formed a Unified Physicians and Surgeons Association to protest and highlight government  shortfalls,  they  have participated in forming nearly 7000 walk-in clinics to service patients without access to a personal physician,  they have been active in forming telemedicine and online virtual visit organizations,   they have developed  outpatient, focused diagnostic and treatment centers, they have developed alternatives to 3rd party care by offering low cost concierge and outpatient surgery centers, and they have become leaders in integrated hospital-physician organizations.
In all of these activities,  one thing has become apparent,  government alone cannot meet the needs and demands  of a population,  now increasingly informed by the Internet and social media about their health care options and continuing to demand the best care medicine has to offer.

What about a single-payer system as a way forward, as proposed by Bernie Sanders in his Medicare-for-all proposal?   Not a chance says Jonathon Oberlander, a health care analyst at the University of North Carolina in the April 14 New England Journal of Medicine, "The Virtue and Vices of Single Payer Health Care."

"Single payer has no realistic path to enactment in the foreseeable future. It remains an aspiration more than a viable reform program. Single-payer supporters have not articulated a convincing strategy for overcoming the formidable obstacles that stand in its way. Nor have they, despite substantial public support for single payer, succeeded in mobilizing a social movement that could potentially break down those barriers. The pressing question is not about whether Medicare for All can be enacted during the next presidential administration — it can’t — but where health care reform goes from here."

"It’s possible that some states could, through waivers that begin in 2017, consider adding a public option to their marketplaces or even adopt single-payer systems. Yet Vermont’s recent struggles to make a modified single-payer plan work underscore the challenges to state action. At the federal level, incremental steps toward Medicare for All, such as expanding program eligibility to younger enrollees, are conceivable — though challenging in this political environment. Moreover, the fight over Obamacare is not over. Preserving and strengthening the ACA, as well as Medicare, and addressing underinsurance and affordability of private coverage is a less utopian cause than single payer. I believe it’s also the best way forward now for U.S. medical care."

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