28 replies »

1. Scott-
   A compassionate doctor would have brought out the salt and ketchup from your break room!

2. A little OT: I had a insulin-dependent diabetic eating a cheeseburger and french fries yesterday in my waiting room. Funny and sad.

3. Correction. I will have to take Canada out of the economic failure column, but France, Italy, Germany and maybe Britain remain. Once oil drops back to $25 then Cananda will prob end up back in the dumps though.

4. Peter- address of post cut off
   https://thehealthcareblog.com/the_health_care_blog/2006/07/an_outcomes_pri.html

5. “How do you measure failure and for whom? And at what point in the oncoming unsustainable future of U.S. healthcare would you consider this system to be a failure? Would it be 80 million uninsured? Tax cuts/unending war/trade deficits/growing incompetent government/borrowing to stay afloat/global warming is a myth – these are signs of a successful government with a sustaining policy?”
   The only way to measure a nation’s failure/success as a whole is to look at GDP. Those numbers don’t lie. Canada, Britain and Western Europe are economic failures due to their craddle to grave entitlement programs. I don’t think many would argue this point. It makes no sense to expand our entitlement programs further unless you want the USA to end up in the mire of stagnant economic decline expemplified by Europe. I am beginning to believe that those from the Left (George Sorros crowd)in fact want this to happen.
   As you can see from the chart below George Sorros, Clinton, Dean et al would like us to hand over the “extra” $11000 we have. In their minds we have no right to that extra $11000 GDP per capita. Canada’s GDP surprised me but I suspect is primarily due to the price of oil.
   Rank Nation %growth GDP per capita
   124 United States 3.50 2005 est $ 41,800
   140 Canada 2.90 2005 est. $ 34,000
   171 United Kingdom 1.80 2005 est. $ 30,300
   197 Germany 0.90 2005 est. $ 30,400
   203 Italy 0.10 2005 est. $ 29,200
   182 France 1.40 2005 est. $ 29,900

6. Peter- I enjoy the debate…
   Ask 10 of your co-workers how much their health insurance costs per month/ per year. Let me know how many know the correct answer. The reality is that few of us — other than those who pay for individual insurance — understand the cost of health insurance. We think of our SALARY + BENEFITS, rather than TOTAL COMPENSATION. Those on the left should really embrace the concept of TOTAL COMPENSATION as it protects workers from under the radar cost shifting. Those on the right should embrace it because disclosure about benefit costs explains to workers the cost of employees. The THCB crowd should like it because it educates us about where the $2 trillion comes from.
   I do not know where your 50% bankruptcy rate comes from– but that is exactly the point — entice business (in this case, health care) to come to an underserved community. This kind of tax enticement is done in other areas with some success.
   Process type measures — vs. outcomes. See my earlier post about an outcomes primer (https://thehealthcareblog.com/the_health_care_blog/2006/07/an_outcomes_pri.html) to understand the different factors impacting outcomes. Just like doctors should not be held to a standard for people losing weight, but perhaps could be held to a standard discussing the impact of obesity on health — patients perhaps should not be held to a standard where they lose 5 lbs/ wk, but could be held to a standard where they keep there HgA1C or blood sugars in a certain range. It does not mean that you prevent sequelae of diabetes, but if you start with the process measures (HgA1C or blood sugar), over time, hopefully you can impact what you are really trying to do, improve the health of the person.
   I guess I could address 3-5 in another post…
   But I have to dispel the myth that 1 payer= simplified billing. You realize that the feds want to go to a system where doctors would have to choose from over 200,000 codes (as opposed to 30,000 currently) to bill. That is not simple, adds admin costs that are not measured by the government.

7. If docs have some patients who rarely, if ever, take their advice, often don’t show up for appointments, don’t take their medication or take it inconsistently, etc., docs should diplomatically discharge those patients from his or her practice (fire them as customers). They should explain why they are doing this and, perhaps, offer two or three alternative referals within the community. For patients who are completely irresponsible, getting “fired” by your doc might be a useful way to convey the message that personal responsibility is important and counts for something.
   I also want to make it clear that I am referring to patients who are being treated for medical conditions. For patients who are asymptomatic, if the doc recommends, for example, a statin drug because it might slightly reduce the risk of developing heart disease, that’s a choice that should be left to the patient’s individual preference and risk tolerance, and the doc should not take offense if his or her advice is not followed.

8. “Ok, so how do you police this decision making”
   Peter, why do you assume that personal health decisions must be “policed”? There are myriads of daily-living decisions that no one “polices”.
   You seem to assume that universal health care ultimately depends on some form of coerced behavior because you think too many other people are too ignorant to know what is good for them, and too unintelligent to figure it out. In that paradigm, policing is required, in order that these other people will be dragged, kicking and screaming, to the health care courthouse to be punished for making wrong choices.
   Perhaps, as you seem to suggest, the nation will not expect people to exercise meaningful personal responsibility for their own health, and the nation will move to single payer health insurance that in fact will immunize individuals from the financial consequences of their own poor health habits. I think this is the wrong way to go, but perhaps the nation is going this way. If so, then I suppose it follows that behaviors would have to be strictly regimented in order to pay for this kind of system. However, I think that’s a mistake; I think people should be expected to take reasonable responsibility for maintaining their own health – both as to their habits and as to finances – and to take reasonable responsibility for the consequences of failure to do so. I think abandoning the expectation of personal responsibility is the wrong way to go (you are sending mixed messages about that, yourself).
   Anyway, your mention of “policing” raises once again for me some of the reasons I am so mistrustful of a national, single-payer health care system. I fear that such a system would be designed by a self-anointed elite who secure the regulatory right to decide these things for the benighted “other people”, and then use the power of the federal government to impose their decisions – any kicking and screaming notwithstanding. Is my fear rational? Maybe, maybe not. I can only tell you it’s real.

9. Posted by: Eric Novack | Aug 31, 2006 10:16:58 AM
   “In exchange for society paying for your healthcare, society expects you to make an effort. If you do not choose to play your part, the rest of us ought not be responsible for continually throwing resources at you.”
   “Not everyone can successfully lose 20, 50, 100 lbs. Not everyone can quit smoking. People do not choose cancer. But you can expect people to make real efforts and measure process”
   Ok, so how do you police this decision making process of, “George, I don’t think you are trying hard enough to lose those extra 10 pounds (playing your part), I think that from now on we won’t pay for your diabetes treatment.” Sounds like that government control you hate. Will we get the healthcare Nazis going through everyones files? “Bill, you’d better do 10 more pushups or we’ll cut off your medicade.”
   “First 5 steps in reform: 1. put health insurance costs on paystubs and w2 (education about overall costs take time, but are essential)”
   I think everybodies healthcare costs are now on the pay stubs – Employer contribution, Employee contribution. Not helping so far. When do you see this “epiphany” happening? Wouldn’t it be starting now given the situation everybody knows we’re in? Recent study – WE’RE GETTING EVEN FATTER!!
   “2. create ‘health access zones’ where doctors get tax credits for the value of care they give to the poor/uninsured (patient eligibility via medicaid channels and monitoring via the IRS)”
   So where would these zones be located – the ghettos, or in Middle America where spiralling healthcare counts for 50% bankruptcy rate?
   “3. allow for welfare style medicaid reform with, at least initially, process type measures (system then would not penalize against the child fall from the monkey bars or breast cancer patient)”
   So when (after initial period) would the system penalize against a child’s fall? Don’t understand “process type measures”.
   “4. allow docs to contract privately with medicare patients for covered services (yes, the cost for complex care might go up, but common care costs could go down from competition)”
   I like the, “common care costs COULD go down” part; in your dreams. Contract privately with medicare patients -sounds like an income preservation scheme. How would that reduce use/costs?
   “5. simplify medical billing — all the transparency laws in the world do not help when there are thousands of codes to choose from.”
   Simplified medical billing is one insurance company, the government, with no collection costs for the doc, and by the way, no extra 9 day payment delay (deficit reduction legislation). How many codes do you wish? Maybe 1 – Saw patient, send money?

10. Posted by: pgbMD | Aug 31, 2006 1:25:57 PM
    “Funny how a Canadian a Britain want to impose their failed socialized government run healthcare systems on us.”
    How do you measure failure and for whom? And at what point in the oncoming unsustainable future of U.S. healthcare would you consider this system to be a failure? Would it be 80 million uninsured? Tax cuts/unending war/trade deficits/growing incompetent government/borrowing to stay afloat/global warming is a myth – these are signs of a successful government with a sustaining policy?

11. “Meanwhile, Scott–if single payer passed, your income tax would go up but your payroll “tax” — the amount you spend on insureance for yourself and your employees — would go away! You can call that a tax increase if you like, but in terms of the difference in actual money, it’s neutral.”
    I.E. we would be paying over 65% of our income to Uncle Sam like the Euros do. The neutral dream is complete BS. Smoke and mirrors. Just look across the Atlantic, I don’t like what I see.

12. “So how come the universal gov insurance paid countries are doing it for less(about half) – rhetorical question – it’s because they control costs.”
    It is called severe rationing and cost controls. Last time I checked we live in a free society with Constituional protections. Currently we have Universal coverage and it is called the failed Medicaid/Medicare system. Bottom line, unlimited government guaranteed medical care will not work in this country, Americans expect more from their healthcare/physicians than the Europeans. No reason to expand a failed system. This cyclical argument keeps going round and round b/w why we should or should not emmulate the failed economic powers of western Europe. I don’t think we need to adopt or copy any of their social welfare systems. Why copy something from a failed economy? Seems to me a guaranteed way to slow down the US economy so that we become a failure like them. Funny how a Canadian a Britain want to impose their failed socialized government run healthcare systems on us.

13. Matthew — DM is important, but must have teeth for enforcement with consequences…
    Every industry iis self serving… but remember that the malaria business, which kills millions of the world’s poorest men, women and children every year, is good, not because of some medical-industrial conspirancy, but rather because environmental activists in the USA would rather see those people die than let DDT be used…

14. Posted by: pgbMD | Aug 31, 2006 5:15:22 AM
    “According to BusinessWeek, Finkelstein believes that consumers opt for more medical services if someone else pays for it. But more important, her research shows that the more significant effect on rising health costs may be that insurance guarantees a steady source of revenue for hospitals and health-care providers. “Such ready cash encourages them to build new cardiac-care centers and stock up on the latest high-tech equipment, knowing it will be paid for,” notes BusinessWeek.”
    So how come the universal gov insurance paid countries are doing it for less(about half) – rhetorical question – it’s because they control costs. Insurance exists because the astronomical costs of healthcare make it impossible, but the for richest, to pay cash. So in your dreamworld of pay cash/no insurance how would we get there, and who would fund all the stuff that a pool of money from insurance provides? Didn’t we have that perfect system before health insurance? Why did society stray to the present dysfunctional system from that perfect way? And how does, “a guaranteed source of revenue” affect the way docs bill? I’d be willing to pay with chickens and pigs, would you accept it?

15. TomH– when it comes to substantive changes in the largest sector of our economy, discretion is the better part of valor. (I have now expended my one and only Shakespeare riposte).
    Your heartfelt sickness of “of magical thinking about the inherent superiority of the market-driven healthcare system” implies that we currently have a market driven system? You know, of course, that we do not.
    I can appreciate your experiences in low-income clinics. I spend a fair amount of time in emergency departments and caring for injured folks all along the socioeconomic spectrum.
    Vast exppansion of federally funded social programs are often called the expansion of the nanny state — because you get all the benefits of getting cared for without the discipline you would/should get from parents.
    You want more federal/state level bureaucratic control with everyone else’s tax dollars (or more likely your and my grandchildren’s tax dollars)? Then offer suggestions as a parent — high expectations, structure, and consequences.
    Peter– strategy and wish… as per above, I think that social programs are good, with the above parameters. In exchange for society paying for your healthcare, society expects you to make an effort. If you do not choose to play your part, the rest of us ought not be responsible for continually throwing resources at you.
    Not everyone can successfully lose 20, 50, 100 lbs. Not everyone can quit smoking. People do not choose cancer. But you can expect people to make real efforts and measure process (I am sure you are in favor of pay for performance for doctors… but why not for patients? It is your money on both ends?)
    First 5 steps in reform: 1. put health insurance costs on paystubs and w2 (education about overall costs take time, but are essential) 2. create ‘health access zones’ where doctors get tax credits for the value of care they give to the poor/uninsured (patient eligibility via medicaid channels and monitoring via the IRS) 3. allow for welfare style medicaid reform with, at least initially, process type measures (system then would not penalize against the child fall from the monkey bars or breast cancer patient) 4. allow docs to contract privately with medicare patients for covered services (yes, the cost for complex care might go up, but common care costs could go down from competition) 5. simplify medical billing — all the transparency laws in the world do not help when there are thousands of codes to choose from
    BTW– increased competition will certainly not increase MD compensation… the good docs should get more, the bad ones should get less.

16. Sorry but the personal responsibility line is BS UNLESS we are prepared to let the obese/drinking/smoking/perverts die on the street outside the hospital. Which we are not.
    So we have to figure out a way of dealing with them. (Which in their little way the DM crowd are trying to do).
    But I am reminded about something Alain Enthoven told me. He said, “if I found a cure for cancer tomorrow, the medical industril complex would find something else to treat instead.” His evidence? In the 1930s some 25% of health care dollars went on treating TB. We DID find a cure for TB, and yet health care costs did NOT go down. We just find more stuff to “treat”.
    That is why we need some type of constriction (of whatever variety) on providers.
    Meanwhile, Scott–if single payer passed, your income tax would go up but your payroll “tax” — the amount you spend on insureance for yourself and your employees — would go away! You can call that a tax increase if you like, but in terms of the difference in actual money, it’s neutral.

17. “The best way to improve the health comes from eating less and better, smoking less or not at all, being responsible for knowing what medical conditions you have and what medications you have and why, keeping -shock- copies of your important medical records with you at home, and not blaming everything on the government’s lack of money or on which party is in the majority.”
    I preach this every day. People just don’t want to hear it. For some reason it is easier to get an MRI and take a pill than to pass up a trip to the buffet line. Please don’t get me started.

18. Ah, Eric. Thou and thy fellow conservatives dost protest too much. You want solutions and I want solutions. Everybody wants solutions. The difference is that conservatives think it all boils down to personal responsibility and the free market, such that any government intervention has an almost impossibly high bar to jump. In your world I am on my own in the search for solutions, and if I screw up, let the consequences fall on my head.
    Anyone who has worked in a safety-net clinic would be impatient with such dogmatic cant about personal responsibility. The patients who walked into my clinic, lacking the plush cushions of income and education, were more likely to smoke, to eat too much, to skimp on preventive healthcare even when free. Puerto Rican patients in particular grow up in a culture that values fried foods and fat babies – similar in that way to the Deep South culture I grew up in. And this was on top of the burdens they faced either as uninsured immigrants or as bewildered navigators of the Medicaid maze. Conservatives see only individuals, but the truth is that these individuals are embedded in communities and cultures.
    There’s nothing wrong with a cool assessment of government and its weaknesses. But I am heartily sick of magical thinking about the inherent superiority of the market-driven healthcare system. That system clearly has its own dysfunctions, and it is not designed to address the needs of our society as a whole. If it were, the California Legislature would not be debating a single-payer healthcare system.
    The past six years of Republican dominance at the federal level have been instructive. The problem for our country is not merely the operational incompetence of the Republican majority. More broadly, we have seen tremendous hits to the credibility of conservative ideals of small government, free-market deregulation and personal responsibility. How are conservatives prepared to confront the problems that we as a society face? Are they even interested in solving those problems, or would they prefer to blame me for being fat and go back to shoveling tax subsidies to trim, physically fit CEOs who visit a personal trainer every morning?
    Unless conservatives are prepared to get beyond Pat Buchanan’s tired talking points, they will become irrelevant to our nation’s policy debate. Personally, I think that would be a shame. But it’s not up to me.

19. Human nature being what it is, I don’t think it is any surprise that most people will spend someone else’s money more quickly and less wisely than their own.
    An executive from Medco recently told me, in a conversation about expensive specialty biotech drugs, that she has seen numerous instances of indivduals who cannot afford their co-pay for these medicines and have too much income to qualify for either Medicaid or one of the industry’s charity programs, ask that the treatment be withheld, esepcially if it will only prolong their (low quality) lives by a month or two anyway. They would prefer to leave a small nestegg to their children or grandchildren rather than see their entire savings swallowed up by healthcare costs. On the other hand, if insurance is paying for everything, well, the sky’s the limit, isn’t it?

20. Got this from the Institute for Health Freedom:
    Is Health Insurance to Blame for Spiraling Medical Costs?
    While many people think that technology is the major driver of rising health costs, new research shows that the spread of medical insurance over the past 40 years may actually be the real culprit. In her paper “The Aggregate Effects of Health Insurance: Evidence from the Introduction of Medicare,” MIT economist Amy Finkelstein estimates that the introduction of Medicare and the corresponding spread of health insurance may account for nearly half the increases in real per capita medical spending between 1950 and 1990.
    According to BusinessWeek, Finkelstein believes that consumers opt for more medical services if someone else pays for it. But more important, her research shows that the more significant effect on rising health costs may be that insurance guarantees a steady source of revenue for hospitals and health-care providers. “Such ready cash encourages them to build new cardiac-care centers and stock up on the latest high-tech equipment, knowing it will be paid for,” notes BusinessWeek.
    This new research may shine some light on the upcoming debate on universal health care and mandatory medical insurance.
    Sources:
    “So That’s Why It’s So Expensive: Blame Insurance, Not Just Tech, for Spiraling Health Costs, Says an MIT Economist,” by Howard Gleckman, BusinessWeek Online, August 14, 2006: http://www.businessweek.com/magazine/content/06_33/b3997089.htm?chan=search
    “The Aggregate Effects of Health Insurance: Evidence from the Introduction of Medicare,” by Amy Finkelstein, National Bureau of Economic Research, April, 2006: http://www.nber.org/~afinkels/papers/Finkelstein_Medicare_April06.pdf

21. Posted by: pgbMD | Aug 30, 2006 12:35:10 PM
    “A pure single payer system is not achievable in the US due to Constitutionality issues.”
    We just need to convince the Christian Reich that NOT having a universal system is some gay rights conspiracy. We’d have the necessary constitutional changes passed in no time.
    Posted by: Eric Novack | Aug 30, 2006 2:58:43 PM
    “The best way to improve the health comes from eating less and better, smoking less or not at all, being responsible for knowing what medical conditions you have and what medications you have and why, keeping -shock- copies of your important medical records with you at home, and not blaming everything on the government’s lack of money or on which party is in the majority.”
    Ok Eric, you keep harping back to this. Is this a strategy or a wish? You keep stating motherhood issues, without giving us how you would get there. Again I say, if pigs could fly we’d save on the transportation costs of getting them to market. And if, under the present FFS/private system, how are all those (in a monopoly)docs going to maintain incomes with less use – maybe keep raising prices?

22. TomH — though I would say I have a strong sense of the importance of freedom and the relative impotence of government, I am and would be very open to solutions that would improve the healthcare of US citizens.
    Lewin group numbers nothwithstanding — either you reduce utilization of healthcare services, especially by those ‘high utilizers’, or you do not.
    The best way to improve the healthcare will come NOT from creating more diseases, NOT from better, more extensive coding, NOT from several culturally diverse committees on healthcare, NOT from counting on federal dollars from taxpayers of the other 49 states to cover costs, NOT from forcing physians to provide care at whatever rate the government determines is reasonable, NOT from the codification and enshrining in law the concept of ‘healthcare by lobbying’ (turning healthcare into ‘lobbycare’).
    The best way to improve the health comes from eating less and better, smoking less or not at all, being responsible for knowing what medical conditions you have and what medications you have and why, keeping -shock- copies of your important medical records with you at home, and not blaming everything on the government’s lack of money or on which party is in the majority.
    If those on the left and right can get behind these issues as a starting point (much like the efforts of the last 48 hours to ‘out’ the shameful Senator Stevens), then we can move forward.
    So, am I an idealogue? If idealogue means sticking to the basics and believing in concepts as simple as 2+2, then I guess I am.

23. “If you eliminate all of the unnecessary admin costs of private health plans, you may save 20% of the costs up front. But that does nothing to stop the acceleration of costs moving forward. All of the admin cost savings would be eaten up in the first 3 or 4 years and then you would be back to square one.
    “Other single payer systems around the would are facing this issue. They may spend less per person and get similar outcomes, but the acceleration of costs is what really taxes the system.
    “I don’t [know] what the solution is and I doubt there is any perfect solution. I’m not even sure that a single payer system would affect my practice.
    “The scariest issue with this CA legislation is that there is no specific source of funding. I already pay about 12% in state income tax and the thought of that going up is very unsettling.”
    No, I didn’t say that – Soctt Robertson said it, a couple of posts above. And what he said is so good, I think every word of it should be repeated at least once, so there it is.

24. A pure single payer system is not achievable in the US due to Constitutionality issues. However, an expansion of Medicare/Medicaid to ALL is definitely doable, but the ability for patients and physicians to easily opt out on a day to day basis needs to be built in to the system to protect patient/physician private contractual rights. None of this illegal 2 year opt out BS that is in the current Medicare system.
    The above is possible, but I fear for the taxpayer once the corrupt politicians get done with it. Is this really what we want?

25. If the single-payer bill created a statewide elected official as czar, Novack would argue that political pork-barrel politics is sure to follow – and he might even be right. After all, who would pay the campaign bills of such a candidate? But since Kuehl has designed the bill to insulate the system somewhat from political pressure, he attacks the “unelected health czar.”
    The problem with ideologues is not that they’re mistaken. Novack is quite knowledgeable. The problem is that the ideology dictates the conclusion, not the evidence. A proper ideologue determines the conclusion (e.g., single-payer is a fluffy-headed liberal delusion) and works backward to the arguments.
    Personally, I’m not sure that single-payer is achievable and workable in the U.S., but at least I’m open to arguments pro and con.

26. As an advocate of Universal Healthcare, I do think that letting the present incompetent program policy management structure in the Washington cesspool of crony paybacks and kickbacks, which manages from the buddy system of ideology, rather than what actualy works, or who can actualy make it work, will make a mess of any government program as big as universal healthcare. I doubt that the states will fair much better as political shit rolls down hill. But at least someone (CA MA)is trying something different. I still don’t think there is enough political will (crisis) to really do more than shuffle the deck chairs.

27. For what it’s worth, I live in New York and am happy to see experiments such the ones in Massachussetts, Vermont, and California. I don;t know how happy I would be to see a similar experiment in New York, but never mind that.
    Mainly these states’ initiatives give us regular folk the chance to see how policy wonks’ theories actually work in real life. I mean, c’mon, climb to the top of the tower and drop the freakin cannonballs. Will the 10-pound ball drop faster than the 1-pound ball? Let’s see.
    So far, it looks as though the wrong cannonball is falling faster. TennCare and all that. But shifting my metaphors, there may be a pony in there somewhere so I say, keep digging. And let the states do it.

28. The CA Bill fails to address the two biggest factors in the acceleration of health care costs: an aging population and the advancement of diagnostic and therapeutic technology.
    Matt made a great point about how cost-ineffective it was to place two stents in the heart of 93yo President Ford. It is this type of situation where the most inefficiency of system takes place. You can talk about physician fees and drug costs until you are blue in the face, but it’s when you get a bill from a hospital or surgery center, it becomes clear where alot of the money is being spent.
    If you eliminate all of the unnecessary admin costs of private health plans, you may save 20% of the costs up front. But that does nothing to stop the acceleration of costs moving forward. All of the admin cost savings would be eaten up in the first 3 or 4 years and then you would be back to square one.
    Other single payer systems around the would are facing this issue. They may spend less per person and get similar outcomes, but the acceleration of costs is what really taxes the system.
    I don’t what the solution is and I doubt there is any perfect solution. I’m not even sure that a single payer system would affect my practice.
    The scariest issue with this CA legislation is that there is no specific source of funding. I already pay about 12% in state income tax and the thought of that going up is very unsettling.