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POLICY: What Would Dubya Do?

So I’m up at Spot-on asking if you really wanted to get to universal care and reward your base, what type of political moves would you have to make. In other words, What Would Dubya Do?

Comment back here if you like.

In the last week the Democrats must have gotten sick of being told that they are supposed to be moderates. The New York Times tells them that populism should trump ideology, the nut jobs on the right still think that they are the second coming of Lenin,
and the corporate-friendly Emmanuel faction is already starting the
fight with the Dean "net roots". Which is why I’m on the record as
saying that no radical health-care reform will happen in the balance of
this decade.

When you look at domestic issues, of course, health care is by
a mile the most important, and the party’s presumptive 2008
presidential candidate Sen. Hillary Rodham Clinton, has, shall we say, a history in the area.
But realistically all that will happen in the next two years is for
Congress to give the administration the right – but presumably not the
obligation – to directly negotiate with drug companies about Medicare
prescription drug pricing. There’s also the likelihood that Congress
will approve a reduction in the bonus profits currently offered to
private insurance plans by the 2003 Medicare Act. But it’s just as
likely that the drug pricing measure will be vetoed by President Bush,
although the cuts in Medicare private insurer reimbursement will likely
be part of a budget act which the President will probably sign. Continue

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18 replies »

  1. Here is a website with real solutions to health care and IRA Reform.
    The Giant Health Mae IRA HMIRA
    Create a non for profit Universal Health Care workforce for the uninsured.
    Staff them in hospitals and clinics.
    Drop current $5million policies to $50k per year by creating a universal (Part B) that covers you from $50k and up per year.
    This makes more sense than insuring the uninsured at a profit.
    It also make more sense than trying to make all of the Dr’s and nurses gov employees like the Canadian system. Do you agree?
    Check out the proposals on http://www.mypaysaver.com.

  2. Matthew—
    Your Spot-On post is great—the best road-map for reform that I’ve seen. I especially like your “divide and conquer” strategy for hospitals and insurers.
    The only point I’d add is that, although drugs and devices directly account for only 15% of our health care bill, indirectly they account for much more—especially the devices… Every time a device is used, we pay not for the cost of the device, but the cost of the surgeon implanting it and the hospital care that follows the surgery. And in many cases, the surgery is not needed—i.e. all of the recent news about stents confirms that we’re doing a large number of unnecessary angioplasties. If those stents were not marketed so aggressively, fewer angioplasties would be done.
    Finally, it seems to me that the comments that follow your post may be putting too
    much emphasis on end-of-life care as the major problem behind health care inflation.. 75% of all health care dollars are spent, not on end-of-life care, but on long-term chronic illnesses—cancer, heart conditions, diabetes, back problems, etc.
    Here health care costs are inflated by overly-aggressive care—all of those unnecessary angioplasties (instead of first treating heart disease with medication), unnecessary back surgery (instead of insisting that the patient try physical therapy),unnecessary prostate “seeding” procedures and surgery (instead of “watchful waiting”), futile rounds of chemo . . . etc.
    In addition, if we paid primary care doctors more to treat obesity (rather than paying specialists much more later on to operate on the obese patient) we could reduce the number of patients suffering from many of these problems.
    Finally, when it comes to end-of-life care, I agree with j.d. The Dartmouth research showing huge regional variation in how much Medicare spends on end-of-life
    care makes it pretty clear that much of end-of-life spending is supply –driven. In other words, if you live in an area with more specialists and more ICU beds, you’re likely to receive more end-of-life care, whether or not you want it.

  3. “You missed the thrust . . . “
    No, I noticed all your thrusting, I didn’t miss it. And I have no problem with data, collect all you want. I said this:
    “To believe withholding ‘futile care’ can work as general social policy – can improve on decisions made within the present doctor-patient relationship – is to place a huge unearned measure of trust in the people who would define ‘futile care’ and, thereafter, in anyone to whom society gives a legal right to make decisions about other people’s ‘futile care’. I am not willing to give that much trust to anyone I have not chosen for myself. Nor would I welcome the erosion of trust in my own physician.” In good conscience, I cannot support treating others in ways I’m unwilling to have myself treated.
    I’m saying that I won’t give such a huge unearned measure of trust to people (other than my own physician or members of my own family) who advocate making end-of-life decisions for me based on glib assurances that the decision “is grounded in solid evidence” and who also advocate “refusing to have the state pay for things that are not.” I think these people will change the medical ethic into a sort of veterinary ethic in which third-party strangers decide the fate of patients according to the third-parties’ needs, not the patients’ needs.
    Of course, it would all be decorated in language designed to persuade everyone that grandma dies with dignity based on warm, compassionate scientific data, not as ther reslt of cold calculating conscience. O brave new world that hath such people in’t!

  4. “One good place to start thinking about how to do that is to acknowledge how much of present health care costs are driven by irresponsible behaviors – poor nutrition; obesity; inadequate physical exercise; unsafe sexual activity; inadequate sleep; drug, alcohol, and other substance abuse; tobacco use; violence and crime; auto accidents; air pollution; stress in the workplace; etc etc.”
    Ah, the American lifestyle, where choice is everything and consequences are for the other person.
    Posted by: jd
    “It is remarkable how physicians seem to hold the scientific method in such low esteem, in favor of some kind of intuitive, I calls ’em as I sees ’em, mentality.”
    This “doctors intuition” has proven to be wrong and wasteful. That’s why there’s “Best Practice” models. In any decision about who can survive and who can not, percentage is always the factor. We do need to produce the science so that docs and patients/family can try to understand where the right decision will be, but it should not be a board or government body that will apply the science.

  5. In any given year, I wonder how many patients are on feeding tubes and breathing machines. These are standard interventions that can extend life for quite some time, albeit with low quality and at high cost. Once treatment like this is started, it may be difficult or close to impossible to discontinue. Many people who do not have living wills or advance medical directives do not want these interventions. If they had the will or the directive, their wishes would have been respected. In Porter and Teisberg’s new book Redefining Healthcare, they suggest making executing a living will or advance directive a requirement of health insurance.
    With respect to ultra expensive biotech cancer drugs coming to market, Congress must give CMS explicit authority to take cost into account (relative to benefits) in determining whether or not CMS will pay for the drug even though it was approved by the FDA. Without some mechanism to balance drug costs with benefits, there is, in theory, no limit to what drug companies can charge as long as there is a payer to pick up the tab.
    Regarding surgical interventions on very sick people, including those with advanced mental illness like Alzheimer’s and dementia, we should redefine what constitutes sound medical practice and look to what other countries with national health insurance do. We should also look regionally within our own country and try to bring about convergence in practice patterns between the best practicers and the high utilizers.
    Spending five percentage points of GDP more on healthcare than the next highest spending country has adverse long term competitive implications for our economy, and we still have 15% of the population that lacks health insurance. This is a problem that is screaming for a solution. Focusing on expensive care at the end of life offers lots of potential to save money and allocate our finite resources more wisely.
    Financing healthcare is a whole separate debate, but there is no reason why the financing debate and the utilization debate cannot proceed at the same time on a parallel track.

  6. John,
    You missed the thrust of my comment and the thrust of many efforts to curb costs of end of life care. My point was that we can get just as much longevity by getting data on which procedures actually tend to improve longevity and add increased misery (the misery of treatment, and perhaps new side effects) and extensive additional costs without prolonging life on the whole. There isn’t magic involved here. It’s just about collecting data.
    You write:
    “I’m not so naive to think that care is never withheld by a physician on grounds of futility. But those decisions are usually made privately, reached as a matter of the physician’s (or family’s) conscience, rather than as the result of explicit social policy.”
    What’s missing from this private scenario is public data. Without it, everyone’s conscience is groping in the dark. The Dartmouth group provides a starting point to understand why some low-intensity systems produce outcomes that are as good as or better than high-intensity systems at a fraction of the cost. The reason I referred to the by-now well known Medicare study is that grandma ended up under the train in every case. It’s just that in one group we paid twice as much to try to stop it. We can build on that information to identify what kinds of practices don’t actually improve outcomes.
    So I’m not talking about throwing grandma under the train. I’m talking about figuring out whether some proposal to get grandma off the tracks is grounded in solid evidence or not, and then refusing to have the state pay for things that are not. Can there be errors? Of course. And these errors can result in deaths that wouldn’t otherwise happen. But the point of collecting more and more evidence is to understand the outcomes, see the patterns, and get better and better at knowing what interventions will help and what won’t. Because right now, by overtreating at the end of life, we hasten death more than prevent it and do aggressive treatments that only add to a person’s misery because they were the wrong treatments. That’s what the Dartmouth group showed. People’s uninformed consciences are leading them to unwittingly throw grandma in front of the train already. I am proposing that we stop that.
    It is remarkable how physicians seem to hold the scientific method in such low esteem, in favor of some kind of intuitive, I calls ’em as I sees ’em, mentality. I agree that intuition has to come into play now due to the widespread lack of adequate data. But the goal should be to keep filling in gaps so that we can guess less often, and so private decisions can incorporate more and more public knowledge.

  7. What would Dubya do? Call his Daddy for Louis Sullivan and Gail Wilensky’s phone number.
    Hospitals have already figured out what service/product lines are dogs and what are their stars. They have quietly begun to RATION care. The conflict will come when the patients (and the public) finally figure out the giant gap between REALITY and hospitals’ well advertised CENTERS of EXCELLENCE. At some point a very bright lawyer (or team of lawyers) will figure out how to pursue a claim of fraud against the hospitals and physicians for saying one thing and behaving in a different way on purpose.
    Matthew: your analysis left out the fifth important group of folks at the healthcare trough — the lawyers (and consultants). How can we thrive under universal health? We have vested interest also.

  8. Just one more thing. I agree with Barry that there is room for improvement in how end of life care is managed in the U.S. But I’m honestly concerned at the implications of trying to deny “futile care” in order to reduce costs, and that is why I’m raising objections.
    I’m not so naive to think that care is never withheld by a physician on grounds of futility. But those decisions are usually made privately, reached as a matter of the physician’s (or family’s) conscience, rather than as the result of explicit social policy. Aside from saving money, is there a reason that matters of a physician’s and a family’s conscience should be fashioned into explicit policy – along with the tort-system reforms and bureaucratic rules that would necessarily accompany that change?
    Do we truly wish to leave our children, and their children, a system under which some independent authority that may or may not include their attending physician, has power to decree which care will be withheld and from whom? Can such a power, once created, be immune from corruption by money or politics? Aside from saving money, would this change represent an important improvement over what we now have?
    We haven’t even touched on long-term care patients, for whom restoration of health or function is not expected, rather their care is needed to enable routine daily activities of living. The cost of long-term care patients is already large. Perhaps a lot of money could be “saved” by withholding their care. Should that be done?
    I think all these questions can and should be faced even while conceding that improvement in the management of end-of-life care is needed. Because when reforms are in place, they must produce something we can live with.

  9. Look, jd, all I’m saying is: before we toss our grandmas under a train somewhere, it makes sense to devote some serious attention toward improving the general public health. In other words, why not try to reduce the cost of health care by reducing demand for it? Maybe then there wouldn’t be so much angst about the cost of caring for the weakest and sickest among us.
    One good place to start thinking about how to do that is to acknowledge how much of present health care costs are driven by irresponsible behaviors – poor nutrition; obesity; inadequate physical exercise; unsafe sexual activity; inadequate sleep; drug, alcohol, and other substance abuse; tobacco use; violence and crime; auto accidents; air pollution; stress in the workplace; etc etc. Because the consequences of these irresponsible behaviors on medical costs are very expensive, why not try to change them? Why tacitly accept socially harmful behaviors? A whole lotta denial going on here is what I think.
    And what is “futile” medical care anyway? To believe withholding “futile care” can work as general social policy – can improve on decisions made within the present doctor-patient relationship – is to place a huge unearned measure of trust in the people who would define “futile care” and, thereafter, in anyone to whom society gives a legal right to make decisions about other people’s “futile care”. I am not willing to give that much trust to anyone I have not chosen for myself. Nor would I welcome the erosion of trust in my own physician.
    Nevertheless based on your post, I suppose it’s probably not difficult to find studies that provide a fig leaf of objective science for proposals to curtail “futile care” for anyone – young, old, or in between. No matter how narrowly “futile care” may at first be defined, willing authorities can be found later, to revise the definition of “futile care” if needed at the moment to balance some budget. Similar willing authorities have appeared throughout history. To believe that won’t happen for “futile care” is, IMO, naïve.

  10. John Fembup seems to live in a world in which the data collected by the Dartmouth Group do not exist. Or maybe he just doesn’t believe it. Because if you do, then you believe that in the American context regions and systems with high-cost, high-intensity end of life care do NOT perform better than those with low-cost, low-intensity end of life care. Minnesota outperforms Florida, at a fraction of the cost, even after you control for health status.
    Heck, their recent study on Medicare even controlled for outcome: everybody died.
    If every state’s medical practices were more like those in Minnesota, we would shave, what, 20% off our health care costs while *increasing* longevity? I don’t have the figure handy, but it is huge.
    You play a lottery by receiving certain types of care as well as by not receiving it. John just looked at one part of the picture.

  11. Peter – I think more widespread use of living wills could make a positive difference and reduce the cost of end of life care. A woman I know who has worked as a nurse in Boston for over 20 years, much of it in the ICU, tells me that when there is a living will, it is honored. If there is a healthcare proxy, they will generally go along with what the proxy wants to do. If neither is present and the patient can’t communicate, the bias is to do everything because of the fear of being sued if they don’t, though there will probably be a DNR order in the chart. Many elderly patients in ICU’s around the country would probably be better served with hospice care or palliation rather than aggressive and expensive interventions including feeding tubes and breathing machines.
    One problem is, in the absence of a living will, middle age children do not know what their parent wants (if communication is no longer possible). Often, because the children have not yet come to grips with their own mortality, they ask the medical staff to “do everything.” The bottom line is that there is enormous room for improvement in how we approach end of life care, and we could probably learn plenty from our friends in Canada, the UK, Western Europe, Japan and Australia that would both enhance comfort and improve dignity for dying patients while saving money for our healthcare system.

  12. Vince–When you say thoughtful I assuem you’re talking about the piece at Spot-on, not the comment about shooting politicians and doctors!
    My overall goal is to create a universal health care system where innovation that encourages cost-effective advances in care (e.g. Disesase managemengent if it can be shown to work) is encouraged.
    That’s extraordinarily difficult, but at the moment we have the exact opposite–a non-universal care system which causes incredible hardships to those who lose the insurance lottery PLUS a financing system that encourages innovation in non-cost-effective care.
    However, if we solve the first problem–which is by far the biggest problem– by getting the government involved in either directly regulating the overall coverage and costs of the system, or setting it up so that other entities do it (a la Enthoven), we will also solve the second.
    Then we’re just left with the problem of how to encourage cost-effective innovation. Frankly, the Brits with their primary care P4P, and the Swedes with their cardiac care are doing a bettter job of that within their “government controlled system” than we are. So I’m not as pessimistic as you are (mr Democrat!)
    Finally to Peter’s point, most of this end of life care is provided within Medicare (obviously) and any serious system reform will need to address this problem somehow–that’s something that I, Eric Novack, David Gratzer and the Church of England all agree on! (And you can’t say that too often!)

  13. I’d be interested to know how many of the so called costly end-of-lifers have or have had any health insurance? I’m thinking that not many of them do.
    I read that the our illustrious prez will also veto any attempt by Dems to allow medicare to negotiate drug prices because (ideology) that would be a first step toward universal coverage. It’s interesting that a guy like Dumbya, who has had a connected and rich daddy to always get him out of scrapes as well as fund him, thinks he knows whats the best way to run a socially responsible healthcare system – or a war.
    “I think reining in futile care at the end of life should be a key area of focus to reduce healthcare utilization and free up resources. A systematic effort to make living wills and advance medical directives more widespread should be part of the strategy.”
    Barry, always thoughtful, but I’m not sure how you would structure the rules. It seems we all know when end or beginning of life health issues seem best solved by death but how do you get the rules down for the docs? What postion does the AMA take on this? There are decisions now being made every day out of the limelight. Do you want those decisions taken out of the hands of patients and their families? I would be against the state, as in Schrivo’s case, telling her husband he has to continue life support (on who’s nickel) or telling him she has to die. Although this country is so perverted that starving is seen more humane than an injection. Do we say to a welfare mom waiting for a miracle from Jesus to save her neo-nate (and spend that $million) that the baby must die? And do we make the same decision for a wealthy mom with health insurance? I also don’t think it’s a question of freeing up resources, there’s plenty around it seems, way too many. Living wills are great, I have one, but I don’t think an effort to get living wills done by everybody would make much difference. Families are making those decisions in absence of any directive.

  14. Very thoughtful.
    When I think about the term “universal coverage”, its often used in the context of both 1) government financial sponsorship of the uninsured, and 2) a government controlled health care system (e.g., Canada, the UK).
    Your arguments seems to go much more toward supporting #1. This makes sense to me because there are minimal market incentives to provide coverage to the uninsured.
    Even tho I’m a Democrat, #2 makes me shudder.

  15. “in general they were willing to trade limits on futile end-of-life care for lower-cost universal insurance. No one usually dares explain this in the Terri Schiavo era, but it is excessive spending on a few very sick people that leads to the overall high cost of health care for everybody.”
    Long ago in a galaxy far, far away, “insurance” was conceived as the most practical means to protect individuals from significant financial risks that no family could absorb, by pooling the risks and sharing the costs.
    We moderns in this galaxy right here have much more sophisticated needs. We need comprehensive first-dollar coverage. Finding that more expensive than we wish, we are willing to throw the weak and infirm under a train so they and their costs – the catastrophic costs that insurance was originally conceived to address – will disappear.
    This week, in the UK, a serious proposal was floated by NHS to withhold care from severely disabled newborns. It’s futile to provide care to these unfortunates, the argument goes, and expensive anyway. So let’s stop it. The Church of England agrees.
    http://www.dailymail.co.uk/pages/live/articles/news/news.html?in_article_id=416003&in_page_id=1770
    Likewise we question whether end of life care for the elderly is, in fact, futile. Indeed, can it not be defined as futile for certain conditions? In that way, the costs incurred for treatment at the end of life can also be reduced based on the futility of providing any care at all.
    Next steps would require only successive modifications to the definition of eligible ages and of the term “futile” and I imagine it should not be so difficult to find some authority willing to modify the definitions when necessary. Such willing authorities have appeared throughout history – at least in our galaxy.
    Therefore I have every confidence that pursuing a strategy of eliminating futile medical care will make insurance affordable. As affordable as if there were a simple lottery in which on some regular schedule, every 10th person above the age of 50 were shot. (Politicians and physicians excluded.)

  16. Thank you Matthew fir your excellent stakeholder analysis. I think much money could be saved by reducing spending on end of life care, which would lessen the need to increase taxes on middle and upper income Americans.
    But I’m hoping you can point me to evidence that insurance companies add value to the health system. That is, can they transform money into services into health better than a larger, public negotiator? With lower administrative costs both on their side and induced on the provider side? You assert that Blue Cross and others can do this, but provide no evidence.

  17. Very good article, Matthew.
    I think reining in futile care at the end of life should be a key area of focus to reduce healthcare utilization and free up resources. A systematic effort to make living wills and advance medical directives more widespread should be part of the strategy. We probably also need QALY metrics or something like it, though only CMS is in a position to assume a leadership position on this, in my view.
    My favorite source of incremental revenue to fund universal coverage is a large carbon tax phased in over 3-5 years. It would not only provide a lot of money without unduly further soaking the rich and upper middle class but would also help to mitigate both global warming and energy consumption. The poor could be protected by expanding the Earned Income Tax Credit (EITC) and raising the standard deduction.

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