Monday, August 17, 2009

Twenty Seldom Heard Stories of Health Reform

1) Everybody, including all major health care stakeholders, agrees reform is needed and care is unaffordable. But the system is not “broken.” We have the best acute care and technology in the world. But the delivery system is fragmented and badly needs streamlining and repair. Adding guaranteed payments for 46 million uninsured is an attractive economic prospect for most stakeholders, but has formidable consequences for taxpayers.

2) Incremental reform, powered by innovation and imagineering, is inevitable and necessary. But total, top-down reform, a do-it-all-at-once-governmental-guided-and-dominated system, may be a form of tyranny. It is non-commonsensical to most freedom-loving, individualistic Americans who dread the though of permanent government-induced debt.

3) Information technologies and their offspring – health 2.0, data mining, predictive modeling, comparative effectiveness, and uniform pricing of episodes of care – are powerful, but are offset by legal objections, human and commercial expectations, desires to live another day, and forces for freedom, choice, and pleasurable behavior.

4) If you take deaths from violence and road accidents off the table, the U.S. has the best longevity statistics in the world. This is particularly true for middle-aged and older Americans who receive the fruits of American life-saving and function-restoring technologies.

5) Medicare and other government programs are not financially efficient. Indeed, because they lack cost controls and are thought to offer free and unlimited access to care, they are rising 34% faster than the private sector and are a formula for national bankruptcy.

6) The private health care sector in an incredibly productive “job machine.” It is the single largest economic sector and will continue to be so in aging societies. It is the largest employer in many cities and regions; and has a positive economic impact.

7) Medicare, Medicaid, and private health plans establish doctor fees, not doctors themselves. The combination of government fee-setting and private AMA, specialist -directed updated code setting, SGR *Sustainable Growth Rate)annual setting of physician fees, and is, in essence, a quasi-single payer system.

8) Doctors and hospitals cannot innovate and set up new, more convenient, and more competitive pricing structures because of an elaborate web of regulations and restrictions on pricing and bundling of services. Liberate consumers, doctors, and market forces, and you will see prices will drop precipitously.

9) Doctors are flexible on pricing and will usually offer discounts when asked. Bargaining and negotiating is permissible and common in today’s economic environment.

10) Medicare and Medicaid pay only 78% of costs of doing business and providing care by hospitals and doctors and are offset by cost shifts to the private sector. If Obama proposals evolve as backers hope, more doctors, perhaps half of the physician community will refuse to accept new government-sponsored patients, and mandates forcing doctors to see these patients may be necessary.

11) Disputes over “death squads” are overstated and an unfortunate choice of words. Living wills, hospice care, and agreements between families and doctors to withhold care are common and growing and are already facts of life.

12) Polls indicate patients rarely feel they are over-treated, or have received treatments against their will. Many patients feel they lack access to the best medicine has to offer; it is payers and government who complain of excessive treatment.

13) Lack of tort reform leads to defensive medicine, practiced by 90% of doctors and resulting in about $200 billion of sometimes unnecessary tests and treatments ordered to avoid potential malpractice claims. Legal reform must accompany health reform.

14) Patient behavior – culminating in obesity, and smoking and drug-related diseases and failure to take drugs as prescribed – accounts for at leasy 10%, perhaps even 20%of medical costs. Consequently,more and more businesses may refuse to employ smokers, illicit-drug takers, obese individuals, or persons who do not accept or follow healthy behavioral guidelines. Government intervention into private behavior and taxing products that contribute to this behavior will evolve into a contentious political issue of the first order.

15) The next big health care crisis, already looming large, will be lack of access to doctors; this will be amplified by the exploding doctor shortages and expanding care to the uninsured; In Massachusetts waiting times to see a doctor are already about 60 days, twice the national average.

16) The alternative to government-directed health reform – market competition with high deductible plans with HSAs – is seldom mentioned by the government-obsessed as an alternative to Obama care, but it is the fastest growing segment of the private insurance market and is reducing costs by as much as 30% because patients have a personal stake in what health care costs.

17) A powerful way to bring down prices would be to shift tax-deductibility from corporations to individuals and to make individual health plans portable. Give individuals tax-credits for health plans, and allow them to shop across state lines. Yet now it often illegal to shop for care across state lines. And, although there are 1300 HMOs and PPOs, large plans often dominate in many states. Why not allow individuals to shop for health plans across the U.S. Surely this is possible with today’s Internet technologies. Individual tax credits and portability would create a climate of choice, freedom, and competition – all essentials for bringing down price.

18) Why not look upon U.S. health supremacy in medical and information technologies as a global investment rather than a global competition liability? Already more patients and medical professionals migrate to the U.S. for care and training; already other countries employ and deploy U.S. technologies; already U.S. health care firms garner more of their business from abroad.

19) Small businesses, the nation’s largest employers, feel the public option and other reforms will mandate coverage and impose an 8% tax or penalties and fines, which is why the U.S. Chamber of Commerce, which represents small business, opposes reform, as now defined in the House Bill.

20) It is not over until it is over; 3 House Committees and 2 Senate Committees are still working on reform; the public option and a Medicare Advisory Committee dictating what procedures and care to pay for, are already off the table; and many Blue Dog Democrats fear for their electoral fates if current town hall meetings are any indication; the central issue right now is probably not health care itself but the sorry state of the economy, continued unemployment, quadrupling of the federal debt, and fear of the growing power of government , which is perceived to have taken over the automobile, energy, and finance industries, and will soon engulf and swallow health care. Center-left mandates do not sell well in a center-right country and have limits. Sooner or later, one runs out of other people's money, and beyond lies debt, debt, debt.

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