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POLICY/TECH: Just a wee bit more on CMS caving to the device guys

I was going to write some more about the CMS capitulation but over at Health Care Renewal Roy Poses has already said it all. Go and read.

This is why the Enthoven plan for putting private entities (or at least non-lobbyable) entities in the middle is perhaps the solution for the US to avoid the whole system getting even more like defense contracting. If the “plan sponsors” got a flat rate (or PMPM) from the government or price sensitive consumers but still had to deliver a mandated uniform benefits package, then they’d have the incentive to beat up on the suppliers.

It is amazing that Kennedy and Kerry can be bought off by their loyalty to Boston Scientific less than a week after Kerry stumps for universal health care. Perhaps he just can’t make the intellectual connection between the high cost of devices and the un-affordability of health insurance. On the other hand, perhaps this country is just ungovernable. We have seen the future and it is Halliburton.

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Tom LeithsnodgrassBarry CarolPeterErie Chapman Recent comment authors
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Tom Leith
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Tom Leith

Peter writes: $150,000 is a pretty low threshhold in your system, what happens when that is reached? Right now I think insurers have a $1- $2 million cap. Peter, you clearly have a fundamental misunderstanding of how QALY is applied in this context. Concievably, the $150K could be spent each year on a particular patient. Realistically that won’t happen until medical technology gets a lot better than it is. But you might spend several $100K this year with an expectation of several years of cure afterwards. To the extent we can obtain more in premiums (or obtain more efficiency) in… Read more »

Barry Carol
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Barry Carol

Peter, I’ll let you have the last word on this thread except to say the the vast majority of people likely to be impacted by QALY metrics (if we had them) are the elderly who are currently covered by Medicare or, in the case of nursing home costs, Medicaid (if poor), both of which are single payer systems for the large populations they serve and financed primarily by taxpayers. And don’t get me started on school vouchers.

Peter
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Peter

So now I see that this is really just another voucher plan, like the education vouchers the Repugs have been pushing. I don’t like education vouchers because it will transfer money from community public schools to rich private schools. Don’t think those poor kids will be able to use their vouchers in the high quality private schools in the burbs as the schools will find additional fees and barriers that will make them just as exclusive as now. The same thing will happen to healthcare, well off people will use the vouchers to help purchase premium care that will set… Read more »

Barry Carol
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Barry Carol

Peter, I think you far overestimate the power of the religious right. Like so much in government, solutions to major problems usually require a crisis or a perceived crisis first. We are probably approaching that point with healthcare, and we are already starting to see some experiments at the state level which will provide some good insight into what works and what doesn’t before we finally develop a national approach. A couple of points on QALY and rich vs poor. First, taxpayers are already paying about half of the healthcare bill in the U.S. between Medicare, Medicaid, Tricare, and conventional… Read more »

Peter
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Peter

“One area where I think we have consistently failed in economic life is not sufficiently challenging interest groups to come up with viable alternatives” There is no way to intellectually challenge religious extremists; who now control the Republican Party. The way to sufficiently challenge them is to make them pay, then see if their fundamentalism is trully God sent. But they don’t have to pay, we can just keep borrowing the money. As for splitting the system into rich pay/poor pay, that’s what we have now. You will get a disproportionate allocation of resources to the rich side and starve… Read more »

Barry Carol
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Barry Carol

Peter – Of course QALY metrics should apply to everyone, not just the uninsured. As for the religious right and any other group that opposes them, I have a simple three word question — what’s your alternative? I assume they are not willing to pay higher and higher taxes to support a do everything for everyone no matter what approach. One area where I think we have consistently failed in economic life is not sufficiently challenging interest groups to come up with viable alternatives when they oppose solutions intended to save money that might affect them adversely. I disagree with… Read more »

snodgrass
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Actually the Boston Scientific lobbying story is a pretty interesting one. Think about the situation they face right now. With a series of new products in hand after the Guidant acquisition that have been linked to serious health problems, potentially major changes looming at the FDA, an uncertain clientele and suspicious distributors (docs). I wonder where their money is flowing. I somehow doubt Democrats are the only recipients of their largesse…
In a Democracy there is a word for this, embarrassing …

Peter
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Peter

Ok Barry, would the application of Qualy metrics be applied to everyone, or only to the unisured? Try to get QUALY metrics used for the religious right, like the case of Terry Schrivo. You’re in for a fight. Maybe it would only be applied to Democrats :>), they’d support that. There is no present political/religious climate here for rational end of life decisions. My wife has witnessed the unisured mother of a brain dead baby clinging to, “God will send a miracle”, while the State spends a million dollars. Patients are in no postion to assess risks any more than… Read more »

Barry Carol
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Barry Carol

C’mon, Peter. We’ve been over this before. I’ve said any number of times that I support systematic rationing of expensive and often futile care at the end of life. My personal preference is for QALY metrics as opposed to artificially restricting supply. I would love to see CMS take the lead in implementing this, since only CMS / the government could do it, and even CMS would have to drive it through our political process first. I also support more widespread use of living wills. Matthew and others have also pointed out that we ration care here too, but we… Read more »

Peter
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Peter

“That is why all of the countries with national health insurance systematically ration care one way or another including restricting supply and/or using QALY metrics.” Here we go again, they (single pay gov plans) ration, and we don’t. “there is always an underlying incentive to delay or deny expensive care to save money and increase profits.” Rationing?? What the gov plans do is attempt to control costs (notice not much of that happening here) in a way that is fairer across the board and still provide universal access. Life is always a balancing act. If we’re doing it better why… Read more »

Barry Carol
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Barry Carol

The problem with a flat rate PMPM is that it is notoriously difficult to estimate costs. Sources of excess costs can range from higher than expected general inflation (including wage and benefit costs), a worse than expected flu season, a relatively small number of extra very high cost cases beyond what was expected and providers driving utilization beyond what was expected to earn more revenue. Beyond that is the risk of external shocks like a terrorist attack or another Hurricane Katrina. To make this work, an insurer or other financially responsible entity would need sufficient capital to cover any cost… Read more »

Peter
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Peter

This government doesn’t work because private, free enterprise industry bribes it not to work, then the same people getting the perks from the bribing run out and say how government can’t solve anything and we need less of it. What they really mean is less of it to work for you, but more of it to work for them. This country is surely on the downslide. If all those foreign dedt holders call their loans that have been keeping this economy afloat – blood bath.

Erie Chapman
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Erie Chapman

As a healthcare leader, I also worry about the impact of the medical-industrial complex on compassion in healthcare. For a GREAT article on this subject, go to a terrific new blog: http://www.journalofsacredwork.typepad.com
Sincerely,
Erie Chapman, J.D.
President
Healing Trust – Nashville