POLICY: Sicko and Healthcare Reform by Maggie Mahar with UPDATE

Michael Moore’s “Sicko” does two things very well.

First, the film makes it clear that in the U.S., even if you have health insurance, this does not mean that you are “covered.”  Everyone knows that many Americans are uninsured. But now, millions of middle-class Americans are beginning to realize that they are UNDERinsured, and Moore drives that point home.

For-profit-insurers spend a great deal of time designing policies that will limit their “losses”—i.e. limit the amount that they have to pay out.  These “Swiss cheese” policies are filled with holes: for example, a policy may pay for surgery, but not rehabilitation after surgery. And this omission is deliberate. As a former claims adjuster tells Moore, when an insurer denies payment, “You’re not slipping through the cracks. They made the crack and are sweeping you toward it.”

Secondly, “Sicko” underlines the signal difference between healthcare in the U.S. and healthcare in other countries: the citizens of other countries take a collective view of the problem.  Or as Moore puts it, they realize that when it comes to sickness and dying, all of us are vulnerable. “In the end, we truly are all in the same boat . . . they live in a world of ‘we’ not ‘me.’”

Of course people in the U.K. Canada and France know that healthcare is not free. (And contrary to what some of Moore’s critics say, he does not pretend that it is.) But since they think of healthcare as a right—something we all deserve simply because we are human—it seems to them fair that, “You pay according to your means [through taxes] and receive according to your needs.”  In this, national health programs that are funded by taxes resemble Medicare: the higher your salary, the more you pay into Medicare. The sicker you are, the more you will take out in benefits.  If you’re lucky, you put in more than you take out.

What “Sicko” doesn’t do is focus on the waste in our system. As Jonathan Weiner observes below, we can’t afford to pay for everything that someone might possibly want. We need to be sure that we are getting value for our healthcare dollars.  In one case, Moore tells the story of a man dying of kidney cancer. Desperate to save him, his wife valiantly tries to persuade insurers to pay for new treatments –including a bone-marrow transplant that the insurance company calls “experimental.”  But the insurer refuses, and a few weeks later her husband dies. This is one of the saddest moments in the film—both husband and wife are very appealing.

Yet it is not clear that the insurer was wrong to refuse the cover the bone-marrow transplant. It is very difficult to tell from the few details given in the film whether it might have helped—but advanced kidney cancer is not curable. Even the newest drugs give the patient, at most, a few more weeks of life. At the same time, it is understandable that both the husband and the wife (and apparently Moore) assume that the insurer was merely trying to save money.

After all, when it comes to making coverage decisions based on medical evidence, for-profit insurers have a pretty spotty record. In the 1990s, when insurers said they were trying to “manage care,” many were simply “managing costs.” For example, some decided which drugs to  include in their formularies  based simply on whether the manufacturer would give them a deep discount. In return for the discount, the insurance company would assure the drug-maker that it would not cover a competing product.. This had nothing to do with which drug was more effective.

As I suggest below (see my most recent post on MedPac ) the public will always be suspicious of decisions made by for-profit insurers—even when their decisions are based on sound medical evidence. For-profit insurers just don’t have the political or moral standing to make these judgments. (By contrast, most patients are much more comfortable with Medicare’s coverage decisions—which is why we need a federal agency testing and comparing the effectiveness of new treatments. )

But if Moore skips over the problems of overt treatment it may be because he knows that this at this point more Americans are worried about undertreatment. And to be fair, no one could examine all of the problems in our dysfunctional healthcare system in a single film. What is important is that Moore says what he says loudly and clearly. He tells a vivid, memorable story—and in the process, he has managed to spur the national conversation about healthcare reform.

This is what scares people like Peter Chowka. If people begin talking about health care, they may begin to think about it. It may even occur to them that perhaps it wouldn’t be so terrible to borrow a few ideas from other countries. As Moore points out, “If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what’s our problem? “

"It’s conceivable, Moore suggests, that we might even learn something from Cuba, a country that spends 1/27 of what we do on care. Of course the film’s Cuban adventure is controversial—and purposefully so. I’ve written about it here  on TPM café where I recount a very funny story Moore tells about his experience with Standards & Practices at NBC– a tale which shows that he knew exactly what he was doing when he took part of “Sicko’s” cast to  Cuba.)
Looking back on “Sicko” Moore says, “I could have played it safe, I know. I could have gone to Ireland. . . . Everyone loves the Irish ….  But you know you have to get people’s attention.”

And, as usual, Michael Moore  has succeeded in doing just that.

UPDATE: A couple Moore on Sicko. A balanced enough review in the NY Times from Philip Boffey, and an interesting one (sadly firewalled) by Timothy Egan about whether Americans live better than Italians (My take has always been that rich Americans live better than rich Italians) — Matthew

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116 replies »

  1. As a veteran, I had to wait 8 months after I came back from OEF to receive sub-standard care for a minor injury, and now I believe universal health care isn’t something we should be paying for- it is a right to be treated fairly, especially medically. Between Medicare and the beauracracy of the Veteran’s Administration Health Care System, we are already paying a lot of the cost that could go to universal health care.
    If we also had a universal health care system, many of the individuals that don’t have health care would be paying into it anyways. There would be less sick and more working which would cause a stronger economy. That would feed back into paying for itself.
    You know, I may be a little wrong, I might be a little right in what I’m saying, but one thing is for certain- what we have now is wrong. It is not okay for this system to carry on like it is. Too many people are dying over stupid things that could be taken care of.

  2. As a first-year medical student, getting a combined MD/MPH degree, I am learning about and debating these same issues in my public health classes with my co-degree classmates. The decaying state of our nation’s health care system and the national burden of health spending is appalling and disheartening. From reading “To Err is Human” to discussing the different insurance and payer systems, we are learning the key basics to health services in the US, and how they differ from comparable foreign systems. What is even more shocking, however, is that my fellow medical students in my school and in schools across the nation, are not learning this too. Medical school curriculums do not include any courses on the health care system, health financing, or health policy. The national board exams ask no questions about these topics. Yet all doctors will be facing these issues every day they practice, and thus we are graduating top physicians who lack an understanding about the system they are working in. It is no surprise to me that some of the resistance to a single-payer system and finance reform is coming from within the professional community. Physicians are isolated from these issues until they are fully engrained in the profession and are benefiting from the existing institutions, and thus it is no surprise that they are hesitant to have their system reformed from outside forces.
    Taken with a grain of salt, I even wish at least “Sicko” was shown on the first day of classes. We need something as a wake-up call. Regardless of differing opinions of its political message, it can be agreed to be an important film for starting a conversation about the health care crisis we face, and there is no better time to start talking about it then when we first enter the field. Fundamental change must include change from within the profession, and an essential piece is that we start educating our physicians about the system they work in.

  3. In a single payer universal healthcare system, a possible solution to the physician reimbursement question is to have most physicians salaried or to create a salary cap. Not popular for sure, but clearly effective in eliminating “overtreatment”. Such is the case in various provinces in Canada, for example.

  4. Looking for some passionate people with web cams,
    to join the debate answer this question, in a video.
    The Federal Government should provide free health care for all Americans.
    Do you agree? yes or no,
    Tell us why, make a video. Use a web-cam or camcorder be funny be creative use animation, clay-mation, wear a mask, make a sock puppet or just stand in front of a blank wall and make your point. Post the link in the comment section on:
    Health care | VideoDebater.com

  5. Funny, I always felt the same way. I opened a practice in a small town with the ideal that I was a community resource and if I provided the community with health care I would be taken care of. Two and a half years later I had to close (after about six months of paying myself $143/wk) because the reimbursement system is no where close to sports cars and six bedroom houses. To straighten out the numbers a bit, your average medical school student has a school loan debt of $250,000!!! that is about 2K a month in repayment. Because I tried to open a pracitice and support it while I got it going I actually owe about 3/4 of a million and I am bankrupt. By becoming a Doctor in this society I have not only mortgaged my future but also that of my children.

  6. I’m not sure this was covered, but I do want to comment on the MD salary in the USA, and why it is actually important to keep it high.
    Every country has a limited amount of natural resources, be it coal, gold, ability to grow crops, etc… Well one of these natural resources that is frequently over looked is the hard working brilliant mind.
    What we choose to do with these resources is vitally important to our way of life. If we squander our fuel sources we become increasingly dependent on foreign interests. If we let all our crops die we starve. If we do not encourage our best and brightest to choose a field like medicine they will likely seek other interests (like law school). The problems with that don’t need to be mentioned.
    So how do we keep our best and brightest pointed in the right direction??? Money. The great motivator. How else are you going to get these men and women to work really hard and sacrifice for four years hoping to be good enough to get into medical school, only to work even harder and sacrifice even more to get a good residency, only to be paid near minimum wage to work 100 hr weeks for 3-5 years??? Not to mention the $100,000 plus debt you inherit while going through these 12+ years of higher education. The only way to do it is the promise of a fancy sports car and 6 bedrooms in their houses.
    I agree that health care should be affordable and available to all, but if it has to be done in a way that does not lower the MD salary. If this happens you will have no one in the hospital to give the health care, and the country will be full of brilliant lawyers doing what they do best.

  7. I agree with most of the review provided above. The key point that you and Moore point out is that “we are all in the same boat” (i.e. we’re all human and will get sick and die).
    For our society, with all its power and money, to have 46 million uninsured people is absolutely insane.
    Healthcare is broken. Can someone please develop a “needs to be radical” plan to fix it???

  8. In NYC it’s easy to get treated for anything you want.
    All you have to say is one word………LAWSUIT.
    Think I’m kidding?Half of the hospitals in NYC are now bankrupt.

  9. I agree with Gooby. Health care in one thing (perhaps of many things) the for profit system cannot do right.
    Doctors, CEOs, and all others at the top of this food chain make way more than they should.
    The result, less care for more money. At least for the poor.
    The biggest misconception I find at health-care reform meetings is this “We all pay for the unisured’s bills” Not true. I am unisured and believe me, most of us pay more than those with insurance. If you own anything, you will pay that bill in its entirety.

  10. Wake up folks. We are supposed to be the greatest nation in the world and yet Europe is leaving us in the dust. We overwork our employees to the point of exhaustion. We give them little or no vacation (compare with Europe), we expect them to be ultra-productive and when we manage to squeeze more productivity out of our workforce + productivity = more work = more profit. In other words, we do not reward the worker, we find more work for them.
    Insurance is out of hand. Hard working people cannot afford the policies and if you have a pre-existing condition or get cancer or another life-threatening conditon. Good luck fightng with the insurance company and good luck trying to figure out your bills. God help you.
    I ran a successful consultancy in the UK. We paid NI & PAYE for ourselves and our employees. They received 4 weeks holiday the moment they were hired.
    National Health Insurance? If you go to the physician, there is no bill, no paperwork. If there is a medical emergency, you are cared for immediately. If you need something that isn’t life-threatening, you may need to wait a month or so (depending on the problem/treatment), but it will be sorted.
    You cannot be denied healthcare. You keep your insurance if you lose your job. You do not have to worry about losing your home if you get sick – due to high healthcare expenses. There is no co-pay. Prescriptions are supplied at your physicians office. No pre-approval crap. So what do you dislike about that folks????
    I love the US and I am a patriot, but I would also love to know that I had care that was as good as what I received in the UK. Why should Europe have it better than us?
    For those of you who think Canadians complain about waiting in line, etc. That is the constant drip from the Insurance industry, corporate America and Fox News. They are brainwashing you.
    Go to Canada, take a poll and ask if they want to give up National Healthcare for a US profit-making insurance type healthcare system. They’ll laugh in your face.
    We have a rapidly aging population and we need to get this sorted. We have way too many lobbyists (healthcare industry, drug industry, etc.) paying our politicians (campaign contributions, etc.) to vote in THEIR best interest – not the way that is best for the US citizen. Washington is heaving with bought off politicians that are political puppets for corporate America. The average citizen has no representation in Washington. This is why nothing has been done to close the border. This is why nothing has been done to ensure that high paying positions go to US workers before foreign workers. This is why corporate America demands cheap labor and the US Government hangs spanish signs in our social security offices – to help the illegals.
    This is why nothing has been done to stop the sucking sound of our unloyal greedy corporations moving to China. For several years now, legislation, manipulation of the currency market, etc. has been designed to profit the rich. The middle class and poor are left in the dust. In the next couple of years, watch the rich buy up all the foreclosed properties. Soon the rich will own you and you will be their slaves.
    So for those of you above who dog Moore and praise corporate America, you OBVIOUSLY are doing fine financially. Let’s face it, those folks driving their luxury cars, bypassing the poor neighborhoods to get to their luxury homes – do not give a monkeys ass about the Middle and lower classes which is why they have adopted the attitude “I’m fine Jack and that’s all that counts”. Until they end up on their backsides, they will fight aganst change. Bravo Michael Moore, you got it right this time.

  11. As many emails my family and I have received across America, I can tell you one thing America needs healthcare reform. There are way too many people who have insurance and find they are not covered or better yet find they have a pre-existing condition…some can’t even afford healthcare. Isn’t it the moral thing to do and make sure all citizens of our great country get the healthcare they so desperately need?
    My family and I are actively trying to have H.R. 676 endorsed. If you believe every American has the right to healthcare please sign our petition! We are presenting to several state representatives in September and need support on this ongoing problem.

  12. Thanks for the great article and information about health insurance. More and more employers are going with higher deductible plans to make health insurance costs more affordable. Some people still go with low deductible or HMO plans, but PPO is more popular lately.

  13. Consumerism and Wellness Programs are the Solution to the National Healthcare “Crisis”
    “The topic that is currently receiving a large portion of media attention is healthcare” explained Rick Knox, Vice President of Knox Associates “I honestly do not look at our country as having a healthcare crisis; With one out of every eight national healthcare dollars being spent on the treatment and management of diabetes (estimated at $79 billion dollars) coupled with who knows how much is being spent on the treatment and management of heart disease – both conditions having a high percentage prevention rate – I look at our country as having a “Lifestyle Crisis.”
    “This so called “healthcare crisis” that is being sold to the America public is just more political propaganda. I am not saying that we do not have issues with American healthcare, but the “fix” is not a single payer socialized program. A significant portion of the fix is Americans taking responsibility for their own actions and behaviors, and unfortunately a large portion of Washington Politicians do not believe in the American People.” explained Knox.
    Consumerism, wellness and disease management programs start at the employer level. Consumerism is defined as anytime the insured/employee has a choice. The best example of how this works is with prescription drugs. Health insurance carriers are providing more and more information on drug pricing and drug alternatives. When the consumer sees the true cost of prescription drugs they are more likely to try a lower priced alternative or generic option. When the alternative drug is successful in treating their ailment – the consumer wins by saving money. In the more traditional co-pay type health plans, the consumer has zero incentive to move to a lower cost alternative and the drug companies win.
    With wellness and disease management, the employer implements a program that provides incentives for the employee to visit a doctor for annual check-up’s and take Health Risk Assessments (HRA’s). Those employees who are at risk would then enroll in disease management programs through a Health Coach in order to better his/her lifestyle. Taking Type II Diabetes as an example, an employee would work with the coach (usually a registered nurse) to implement a diet and exercise program that would help the employee manage their condition. Through early detection and diagnosis we prevent those large dollar claims that are causing our healthcare spending to spiral out of control.

  14. I wonder if anyone would find it interesting to read the court decision regarding Michael Moore’s indictment of Kaiser Permanente? Look it up on the web under Dawnelle Barris versus Los Angeles County.
    See, King/Drew hospital and the doctor on duty were found guilty of malpractice and “dumping” in the Mychelle Williams case. Mychelle mother, Dawnelle Keys (later Barris) won the case. King/Drew hospital is a government owned and operated facility. Wonder why Moore didn’t mention that?
    Wonder why Moore didn’t mention many other facts too? Experimental treatments are no way to prove a case for UHC.

  15. http://hometown.aol.com/kstbylite1/myhomepage/business.html
    SICKO had U.S.Attorneys Worried, but alas, Mr. Moore didn’t expose them for thier crimes……
    What Micheal Moore left out of his movie [ That apparently U.S.Attorneys got worried they would be exposed in thier part of Federal Health Insurance Fraud against Americans ] is how these ‘ Managed Care/HMO ‘ Contractors get away with Allowing HMOs to klll thier Federal and ‘ Private ‘ Beneficiaries by Denial of Medically Necessary Services – CITE: 42CFR417 DHHS HMO Grievance Service/Anti-dumping Violation/Fraud by Fright/white collar crime, to Force illegal State HCFA Medicaid kickback applications — ecomonic crime resulting in serious bodily injury or death to the American Citizen with an HMO Policy.
    I live in Michigan, whereas our Governor and Attorney General are illegally using the Michigan ‘OFIS Office’ to conceal and allow Federal HMO Hospital Insurance Fraud [ Anti-dumping & Anti-kickback Violations ] against Michigans Elderly, to Force HCFA Medicaid kickback conversions. Evidence/Documentation Enclosed.
    The U.S.Attorneys and Office of Inspector General were probly PLEASED to see Mr.Moores film Promoting ‘ Universal Health Care ‘ because they want to get rid of the Evidence befor they are Exposed for Managed Care Fraud and Abuse/Economic Crimes, AND they can use the Fraudulent Amounts to Claim what Amount Universal Health Care would START at. Americans are currently paying about 400 BILLION for Denied Covered Services now – 2007.
    Please help expose Public Official Criminal Misconduct – Economic Crime/Federal Hospital Insurance Fraud – America needs ‘rule of law’, Not organized crime denying us Civil and Criminal Rights for Due Process of Law through ‘ grievance services ‘ <~ this is NOT Law Enforcement.
    Kimberly Kimball
    10073 Bryce Road
    Kenockee Twp MI 48006
    The criminal liability of individuals [ Law Enforcement Officials ] through whom the entity [ Federal [ OPM FEHBP etal ] HMO Contractors & thier affiliates ] committed its acts [ Hospital Insurance Fraud T42CFR417 Anti-dumping Violation ] should be investigated and should be resolved separately from the entity's liability. Public Official Criminal Misconduct/Consumer fraud/etal.
    1998 –U.S.Attorney & DHHS Office of Inspector General – T18CFR371Crime Illegal Agreement – ecomonic crime T18CFR286 – Concealing & Allowing Federal Hospital Insurance Fraud, for illegal HCFA State Medicaid kickback conversions – Fraud by Fright / white collar crime – illegal denial of Medically Necessary Services of Federally 'Covered' Claims, through criminal use of the 'DHHS T42CFR417 HMO Government Grievance 'Service' – resulting in serious bodily injury or death.
    1998 –U.S.Attorney & DHHS Office of Inspector General Health Care Fraud and Abuse Control [ DHHS T42CFR417 ] Account would be established as an expenditure account within the Federal Hospital Insurance (HI) Trust Fund.
    "SiCKO": The Profits of Life and Death
    By Sari Gelzer
    Moore shows the American healthcare system thru the lens of insurance
    company whistleblower Dr. Laure Peeno, who testified before Congress that
    she "denied a man a necessary operation and thus caused his death." She went
    on to say that her actions were rewarded: "This secured my reputation and it
    ensured my continued advancement in the healthcare field."
    Why is it that the News Media refuses to show the White Collar Crime/Administrative Fraud regarding Felony Federal Health Care Offences against American Citizens ?
    We can't stop Federal Health Care Fraud & Abuse without your help.
    Denial of necessary services [ DHHS T42CFR417 ] is fraud by fright/white collar crime, whereas DHHS Employees, Federal HMO Employees and OPM FEHBP [ other federal contractors/TRICARE etal ] Employees are protected from federal prosecution for Federal HMO Hospital Insurance Fraud.
    1998 — HEALTH CARE FRAUD AND ABUSE CONTROL PROGRAM [ subject to prosecution ], under the Joint Direction [ T18CFR371-illegal agreement to induce forfiture of Hospital Insurance Benefits DHHS T42CFR417 Anti-dumping violation ] of the ATTORNEY GENERAL and the Secretary of [ DHHS ] the Department of Health and Human Services (HHS)(1), acting through the Department's [ OIG ] Inspector General (HHS/OIG), Designed [ HMO Grievance Procedure T42CFR417 criminal denial of covered Hospital Insurance claims/Volentary Disclousure/SELF-Audit Program ] to coordinate Federal, State and Local Law Enforcement activities [ misprison of a felony / defrauding federal health insurance programs OPM FEHBP CITE: 5CFR890.105 ] With Respect to ( Claims ) Health Care Fraud and Abuse. Misprison of a felony T18CFR24CRIME.
    1998 — The Health Care Fraud and Abuse Control Account would be established as an expenditure account within the Federal Hospital Insurance (HI) Trust Fund.
    CITE- 18 USC Sec. 1518 01/02/01-EXPCITE- TITLE 18 – CRIMES AND CRIMINAL PROCEDURE PART I – CRIMES CHAPTER 73 – OBSTRUCTION OF JUSTICE-HEAD- Sec. 1518. Obstruction of criminal investigations of health care offenses -STATUTE
    1998 Health Care Fraud and Abuse Control Program –INDUCED FORFITURE — Hospital Insurance Fraud – enacted by Hospital DHHS Employees ' discharge procedures/anti-dumping violation/felony fraud/intent to harm- TITLE 42-[ DHHS ]-PUBLIC HEALTH HUMAN SERVICES PART 417-[ Federal HMO ]-HEALTH MAINTENANCE ORGANIZATIONS, [ Special Services / misprison of a felony ] Subpart B-( HMO )- Qualified Health Maintenance Organizations: " Services " (g) Grievance procedures: DENIAL OF Existing OPM FEHBP HMO Hospital Insurance Services [ DHHS Anti-dumping violation for criminal HCFA Medicaid kickback conversions ]. (h) " Special " rules : Enrollees ( Covered Individuals ) under the Federal Employee Health Benefits Program ( FEHBP ). An HMO that accepts enrollees under the ( OPM ) FEHBP (Chapter 89 of title 5 of the U.S.C.) may obtain and retain Federal qualification if….[ 1998 OIG Volentary Disclousure Program/illegal agreement to Induce Forfiture DHHS enactment T42CFR417-criminal denial of OPM FEHBP Hospital Extended Care Benefits w/OPM FEHBP CITE: 5CFR890.105 criminal denial of covered claims – approx Value $288,000 each defrauded individual / ' General Public ' – to force criminal HCFA Medicaid kickback applications/conversions -T42CFR417 DHHS employee and Federal HMO employee Hospital Dumping ]
    DHHS & Federal HMO T42CFR417 'grievance procedures' – denial of Covered Hospital Insurance Benefits & Services, to induce forfiture of existing Federal HMO Insurance to Force illegal HCFA State Medicaid kickback conversions. …..
    1999 RULES & REGULATIONS Part IV DHHS OIG 42 CFR Part 1001 . Federal Health care Programs: ( OPM FEHBP ) . Fraud & Abuse Anti Kickback Statutes Sect 1128B(b) of the Social Security Act provides criminal penalties for individuals [ DHHS employees ] or entities [ Federal HMO employees ] that knowingly & willfully [ DHHS & Federal HMO T42CFR417 Anti-dumping Violation ] offer [ illegal medicaid application ], pay, solicit [ illegal medicaid application ], or recieve renumeration to induce [ DHHS inducing forfiture Existing OPM FEHBP Hospital Insurance T42CFR417 for criminal HCFA Medicaid kickback conversions ] the referral of business reimbursable under a Federal Health Care Program ( including Medicare & HCFA Medicaid ). Section 2 of the Medicare and Medicaid Patient & Program Protection Act of 1987 ( MMPPPA )
    The Federal HMO Programs affected by DHHS T42CFR417/T18CFR286 Hospital Insurance – Fraud by Fright / White Collar Crime – resulting in death by criminal denial of covered T42sec409.33/posthospital extended care Claims – are:
    TRICARE (including coverage provided by the Uniformed Services Family Health Plan)
    The criminal liability of individuals ( Law Enforcement Officials ) through whom the entity ( Federal [ OPM FEHBP etal ] HMO Contractors & thier affiliates ) committed its acts ( Hospital Insurance Fraud T42CFR417 Anti-dumping Violation ) should be investigated and should be resolved separately from the entity's liability. ( Public Official Criminal Misconduct/Consumer fraud/etal ).
    DHHS OIG News Release 21 October 1998
    Volentary Disclousure of Health Care Fraud > 1998 – ATTORNEY GENERAL and the Secretary of [ DHHS ] the Department of Health and Human Services (HHS)(1), acting through the Department’s [ OIG ] Inspector General (HHS/OIG), Designed [ DHHS HMO Grievance Service T42CFR417 Anti-dumping Violation/induce forfiture/criminal denial of covered Federal Hospital Insurance claims – Illegal Agreement T18CFR371 to defraud Federal Hospital Insurance Programs and Entitled Federal Beneficiaries with respect to Claims T18CFR286Crime ].
    The 1999 DHHS OIG Beneficiary Outreach Program, in part, encourages [ General Public/entitled/covered ] individuals to contact the HHS/OIG Hotline, 1-800-HHS-TIPS, which receives complaints of improprieties in Medicare and other HHS programs.
    Subj: RE: HHS OIG Hotline Web Submission – 1998 AG & OIG Health Care Fraud and Abuse Control Program – Volentary Disclousure-SELF-Audit Program – misprison of a felony/T18CFR371/1999 beneficiary outreach program.
    Date: 2/13/2003 10:29:22 AM Eastern Standard Time
    From: hhstips@oig.hhs.gov (Tips, HHS)
    To: Kstbylite1@aol.com
    Ms. Kimball:
    This is in response to your email of February 5, 2003, regarding the [ DHHS -employee- Denied T42CFR417 ] health care coverage [ Federal HMO -employee- Denied T42CFR417 Region V HCFA ] for your [ OPM FEHBP Hospital Insurance Fraud/Dumping Victim ] deceased mother.
    Although WE ACKNOWLEDGE that you have SERIOUS CONCERNS [ Hospital DHHS Workers conducting HMO Hospital Insurance Fraud – T42CFR417 Anti-dumping and Anti-kickback violations Against Retired FEHBP to Force criminal HCFA Medicaid kickback conversions ], it is our judgment that the issues [ Federal Hospital Insurance Fraud ] do Not fall under the Jurisdiction of the Office of Inspector General.
    Since your mother was a federal employee ( Covered Individual ), her FEHB would have been administered by the the Office of Personnel Management (OPM). If you contend that her FEHB [ Federal HMO Contractor ] insurer failed to [ Supply -DHHS and Federal HMO ‘Service’-T42sec417 DENIAL of Existing OPM FEHBP Hospital Insurance ] pay for contracted services, OPM would be the proper agency to handle [ SELF-audit CITE: 5CFR890.105 criminal denial of COVERED Claims ] your ( Criminal ) complaint.
    Inspector General’s Hotline – [ illegal agreement to induce forfiture of existing federal insurance for criminal HCFA Medicaid kickback conversions T18CFR371Crime ].
    400.603 Application for, or Determining Rights to, medicaid benefits; false statement or false representation of material facts; concealing or failing to disclose certain events; felony; penalty. [M.S.A. 16.614(3) ] …………. DHHS T42CFR417 Hospital Insurance Fraud by Fright /Anti-dumping violation and OPM T5CFR890.105 Criminal DENIAL of COVERED Hospital Insurance Claims to Force illegal HCFA Medicaid Kickback Conversions – misprison of a felony ‘grievance procedures’ DHHS & Federal HMO Hospital Dumping.
    1998 — The Health Care Fraud and Abuse Control [ DHHS OIG Volentary Disclousure of felony Federal Hospital Insurance fraud and abuse ] Program — subject to prosecution T18CFR1001 Color of Law/misprison of felony – Criminal Denial of posthospital extended care services T42CFR409.33 against the Elderly DHHS T42CFR417 results in death.
    Read the October 2006 Health and Human Services (HHS) Office of Inspector General report on Medicaid payments for deceased beneficiaries – for more insite into the Criminal Abuse [ Federal Hospital Insurance Fraud T42CFR417 ] Against Elderly American Citizens with Federal HMO Policies.
    The Largest Retirement Savings Plan in the U.S.A. with 1.8 million FEDERAL EMPLOYEE contributiors. treated as a ‘ trust ‘ fund, exempt from taxation ( Tax Reform Act of 1986 Section 1147 Title 26 U.S.Code 7701 ( j ). THRIFT SAVINGS PLAN ( TSP ) G Fund ( gov securities investment fund )
    Retired OPM FEHBP Health Insurance Preiums are taken out of Retiree Checks Befor they recieve thier checks. These ‘ Federal Beneficiaries ‘ are paying for ‘Hospital Extended Care Benefits’/Services, that has not been available to them since the 1998 DHHS OIG Volentary Disclousure Program was created to defraud them of that benefit – DHHS T42CFR417 automatic denial of Hospital Insurance Benefts, to force illegal HCFA State Medicaid kickback conversion – eligibility / Poor.
    The United States Office of Personnel Management
    Office of the Inspector General Fraud Hotline
    1900 E Street, NW, Room 6400
    Washington, DC 20415
    Office of Inspector General – Misprison of a felony – T42CFR417 ‘ grievance service ‘ Hospital Insurance Fraud
    Office of Personnel Management – CITE: 5CFR890.105 criminal denial of Covered Claims
    Joseph Frech investigator – illegal agreement w/U.S.Attorney General & DHHS OIG Volentary Disclousure / Self-Audit / misprison of a felony – Program
    dtd: 9 may 2002
    ” The matters discribed [ Anti-dumping and Anti-kickback Violations – Hospital Insurnce Fraud resulting in Death of a Retired FEHBP ] in your letter are not within the jurisdiction of this office. The OIG had also recieved information regarding your case in September 2000. At that time we determined that the [ OPM FEHBP ] Health Benefits Contracts Division has sole jurisdiction over [ SELF-Audit ] your ( criminal ) complaint. The decision made by the contracts division is final and The OIG will NOT Investigate. ” [ OPM FEHBP Contracting Divisions assisting, allowing & concealing CITE: 5CFR890.105 felony federal health care offences against Retired FEHBP ].
    OPM FEHBP [CITE: 5CFR185.104] PROGRAM FRAUD Sec. 185.104 Investigation. (d) Nothing in this section modifies any Responsibility of an Investigating Official ( OIG ) to Report Violations of Criminal Law [ DHHS Anti-dumping & Anti-Kickback Violations T42CFR417 Against Retired ‘Entitled’ Federal Beneficiaries CITE: 5CFR890.105 for criminal HCFA Medicaid kickback conversions T18CFR286 ] to the U.S.Attorney General.
    Office of Inspector General – Misprison of a felony T42sec417 Hospital Insurance Fraud
    Office of Personnel Management – CITE: 5CFR890.105 criminal Denial of Covered Claims
    Dated: 14 May 2003
    Joseph Frech Investigator – T18CFR371 illegal agreement to defraud Entitled Individuals and Federal Health Care Programs with respect to claims
    C 03-206 Quote:
    ” Your only recorse is to file suite against the Office of Personnel Management in Federal Court. ”
    1998 – ATTORNEY GENERAL and DHHS OIG Designed [ illegal agreement to induce forfiture of Existing Federal Hospital Insurance Services ] the HMO Grievance Service T42CFR417 criminal denial of covered Federal Hospital Insurance claims – misprison of a felony federal health care offence
    OPM TITLE 5 > PART III > Subpart G > CHAPTER 89 > Sec. 8912. Prev | Next Sec. 8912. – Jurisdiction of courts – The District Courts of the United States have Original Jurisdiction, concurrent with the United States Court of Federal Claims, of a civil action or claim against the United States founded on this chapter.
    Chambers of Honorable George Caram Steeh
    United States District Judge [ Appointed by Clinton 1998 ] 1998 AG and DHHS OIG ‘Health Care Fraud and Abuse Control / Volentary Disclousure of Health Care Fraud Program’ for Federal Contractors to defraud the United States and Covered Federal Beneficiaries -DHHS T42CFR417- with respect to Federal Hospital Insurance Claims T18CFR24CRIME.
    Kimberly Kimball
    Office of Personnel Management OIG
    & The State of Michigan
    Case # 03-75161
    The lawsuite was dismissed [ Obstruction of Justice – misprison of a felony ] by the District Court, SUA SPONTE [ without the litigants having presented the issue for consideration / T5CFR890.105 denial of Entitled Judicial Review ],for amoung other things ‘Lack of Jurisdiction’ in JANUARY 2004.
    EASTERN DISTRICT OF MICHIGAN Chambers of Honorable George Caram Steeh -T18CFR371Crime misprison of felony: DHHS T42CFR417 Federal Hospital Insurance Fraud.
    MAY 2004
    Subject: FBI Response
    Date: 5/26/2004 10:26:33 AM Eastern Daylight Time
    From: tips11@fbi.gov
    Reply To:
    To: LawISAmootIssue@aol.com
    Sent on:
    Sent from the Internet (Details)
    Dear Ms. Kimball,
    Thank you for your submission to the FBI Internet
    Tip Line. After a careful evaluation of your
    information, it is our determination that your
    complaint should be reported to your Local Law
    Enforcement authorities or District Attorney’s
    office. If you wish pursue legal matters against
    the hospital you should contact an attorney.
    LOCAL LAW ENFORCEMENT: Government/Grievance/Inquiry Unit -T42sec417 illegal agreement Misprison of a felony / Hospital Insurance fraud
    Michigan Attorney General – health care fraud division # 2002-04-0925 – Mike Cox / Jennifer Granholm <~ Former U.S.Attorney / Current Governor
    Health Care Fraud Division # 99-05-1034 January 2000 Linda Damer
    Insurance Bureau [ OFIS ] #31302-001 March 2000 Cindy Mielock , Kristie Tabor
    Liscensing Division #68-99-3073-00 april 1999 Cynthia Samuel – victim still living
    Bureau of Health Systems #990759 april 1999 Mary Duncan – victim still living
    ACE Eastern District Ellen Christensen USAO refused to investigate 2001 – T18CFR286/T18CFR371.
    USAOs continue to cooperate closely with numerous federal, state and local law enforcement agencies who are involved in [ 1998 AG & OIG – ' Health Care Fraud and Abuse Control / Volentary Disclousure of Federal Health Insurance Fraud [ induced forfiture for illegal kickback conversions into Other Federal Programs ] Program – T18CFR371 illegal agreement / misprison of a felony T18cfr24crime ] the prevention, evaluation, detection, and investigation of health care fraud. In addition to the HHS/OIG and HCFA, these agencies include the State Medicaid Fraud Control Units; Inspectors General Offices of other federal agencies; the Drug Enforcement Administration; Department of Defense, Defense Criminal Investigative Service; and the TRICARE Support Office in the Department of Defense.
    1998 –U.S.Attorney & Office of Inspector General – Health Care Fraud and Abuse Control Account would be established as an expenditure account within the Federal Hospital Insurance (HI) Trust Fund.
    18 USC Sec. 24 01/02/01-EXPCITE- TITLE 18 – CRIMES AND CRIMINAL PROCEDURE PART I – CRIMES CHAPTER 1 – GENERAL PROVISIONS-HEAD- Sec. 24. Definitions relating to Federal health care offense-STATUTE-
    U.S.Justice Department workflow number 7 1998 2
    14 February 2005
    U.S.Department of Justice
    Executive Office for United States Attornies
    Washington DC 20515
    Dear Congressman Stupak:
    Regarding: CITE: 5CFR890.105 Filing for Denied Covered Claims/misprison of a felony
    Judicial Review Denied – CITE: 5CFR890.105 misprison of a felony/T18CFR371
    Violation of Crime Victims Rights – Under federal law [42 U.S.C.10606(b)] and also 42 USC 1983. Civil action for deprivation of rights and The U.S. Constitution: Fourteenth Amendment.
    " This is in responce to your letter to William E. Moschella, Assistant Attorney General for Legislative Affairs, on behalf of your constituent, Mrs. Kimberly Kimball. We apologize for any inconvience our delay in responding may have caused. "
    "We have carefully reviewed the issues raised in Mrs. Kimball's letter, " [ FEHBP killed during the commission of a felony as threatened – T42CFR417 federal health care offence, anti dumping / anti kickback violations ]" but have found no issue upon which DOJ can provide assistance."
    "Mrs. Kimball alledges that the ( Federal HMO ) Health Maintenance Organization that provided ( DENIED ) health care coverage ( OPM FEHBP Hospital Insurance Benefits ) for her Mother IS Engaging in Medicaid [ kickback ] Fraud, and caused [ & are concealing ] her mothers ( murder ) death, by it's use of Managed Care [ DHHS Federal HMO Service T42CFR417 Hospital Insurance Fraud – misprison of a felony T18CFR371Crime ] Grievance Procedures. "
    " It is our understanding that Mrs. Kimball refered her allegations [ because of Public Official Criminal Misconduct T18CFR371 ] to federal law enforcement agencies charged with investigating health care fraud and that they ( OIG's ) have declined further investigation after due consideration. " [ Obstruction of Justice T18CFR1518 ]
    "In addition, we note that public records reflect that your constituent filed a lawsuite in the Eastern District of Michigan [ PER CITE: 5CFR890.105 Judicial Review ] asserting these and other allegations ( RICO ) against the Office of Personnel Management ( OPM ), which contracted with the health insurance carrier [ OPM Hospital Insurance Service Contractor – affiliate – Health Alliance Plan Detroit MI ] that Apparently Denied coverage of her mother. " [ Felony Hospital Insurance fraud resulting in death by criminal denial of covered claims/posthospital extended care services- Fraud by Fright/White Collar Crime ]
    "As you may be aware, the United States Attorney's Office generally do NOT investigate allegations of crimes [ LIE ], but rather Prosecute cases developed by investigative agencies."
    The criminal liability of individuals [ Law Enforcement Officials ] through whom the entity [ Federal [ OPM FEHBP etal ] HMO Contractors & thier affiliates ] committed its acts [ Hospital Insurance Fraud T42CFR417 Anti-dumping Violation ] should be investigated and should be resolved separately from the entity's liability. Public Official Criminal Misconduct/Consumer fraud/etal.
    "We are sorry that We Cannot be of further assistance ( Title 18 U.S.C. § 4. Misprision of felony/T18CFR371 illegal agreement to Allow fraudulent insurance acts against Elderly Hospitalized American Citizens with Federal HMO Policies ) in responding to your constituent. Please do not hesitate to contact the Department of Justice if we can be of assistance in other matters."
    Marry Beth Buchanan, Director
    Executive Office for United States Attornies
    T18CFR1518 Obstruction of Justice T18CFR371– 1998 DHHS OIG & U.S.Attorney – Health Care Fraud and Abuse Control / Volentary Disclousure Program: criminal denial of covered / Existing Federal HMO Hospital Insurance Claims resulting in death of Federal Beneficiaries
    Subj: RE: US Attornies conceal Hospital HMO Insurance fraud
    Date: 9/22/2005 1:47:54 PM Eastern Daylight Time
    From: NewCase.ATR@usdoj.gov
    To: LawISAmootIssue@aol.com
    Sent from the Internet (Details)
    Dear Ms. Kimball:
    Thank you for contacting the Antitrust Division of the U.S. Department of Justice. Upon review of your email, we have determined that your complaint does not fall under the purview of the Division.
    Thank you for your interest in the enforcement of federal antitrust laws, and we wish you the best in resolving your concerns.
    New Case Unit
    Antitrust Division
    Homeland Security and Governmental Affairs
    Subj: Re: Your Concerns
    Date: 3/26/2007 1:16:37 PM Central Standard Time
    From: senator_levin@levin.senate.gov
    To: JustmyOpnion@aol.com
    Sent from the Internet (Details)
    Dear Mrs. Kimball:
    Thank you for sharing your thoughts with me regarding HMO [ Hospital ] dumping. I will certainly keep your thoughts in mind should this issue come before the Senate.
    Best wishes.
    Carl Levin
    All Entitled Federal Employee Health Beneficiaries being criminally denied [ DHHS T42CFR417 ] Existing Federal Health Insurance Coverage Title18CFR1001Crime

  16. What if health insurance companies could only be owned by their policyholders?

  17. I am a physician who believes that a single payer health care system is an imperative for the long term viability of American health care. I believe that it is obscene that there is no true safety net for all Americans. Though I applaud “Sicko” for its impact on the psyches of Americans and its demand for some sense of fairness in health care delivery, I am disturbed by details in the film that so outrageous that they threaten the credibility of the messenger.
    Foremost, the Skid Row scenes are absurd in that the premise is that these people are taken to Skid Row and unceremoniously and cruelly dropped off because “they can’t pay their hospital bills”. This is untrue. They are dropped off on Skid Row because our society has no destination in which to place these unfortunates. It is not the job of the hospital to solve all of society’s ills- the City Union Mission is often the only option for the homeless.
    The “fingertip” scenes are provocative yet beg discussion. We all want all of our bodyparts for all of our lives, but sometimes that is simply not possible or reasonable. Fingertips get amputated by accident or irresponsible behavior, and they are rarely replanted in any country for the excellent reason that you can function fine without them. Is it really society’s or the busy surgeon’s responsibility to provide “free” cosmetic surgery to all who ask? This scene should not have been juxtaposed with the Canadian’s plight of amputating all of his fingers- one cannot function well without the use of his hand.
    The only way a Universal Health Care System can ever be successful is if we, as a society, are willing to make some tough choices of what health care we will pay for. Cosmetic surgery-no; amputated hands-yes. The free choice of any of five osteoporosis drugs-no; the negotiated lower price for one-yes. Truly experimental treatments outside of an established research protocol-no; evidence based treatments and innovative treatments within an established research protocol-yes. Four wheeled “rascals” for every elderly patient with a limp-no; renal transplants and dialysis for the hopelessly vegetative-no; endless choices for drugs of clinically equal efficacy-no. Universal Health Care will only succeed if Americans are willing to abandon their demand for instant gratification and look beyond their own unique selfishness to what is best for our society to survive and function most effectively and efficiently.

  18. Maggie;
    I am shocked about your statement of 2 applicants for every U.S. med school position. After I had to bust my buns to get in in 1973, and I suspect it was mostly because I was a woman and they were under pressure at my med school to admit more women. Up till now I’ve
    avoided answering your prediction that women will comprise the majority of physicians in the future, but
    I believe your prophecy will prove true. I will avoid the wrath of physician readers by explaining why I think that’s true, but there is one caveat – women tend to work best in a collaborative and cooperative system, not an unstable and viciously competitive one. Make our system better and I think you will see more applicants, mostly female. What will happen to nursing, however, is another story…..

  19. Maggie,
    I’m basically in agreement with you on the preventive care co-pays before the deductible kicks in including the drugs for diabetes, asthma, etc. My preference, though, would be to have an independent agency like the AHRQ attest to the cost-effectiveness of various treatments based on good, unbiased research and sound science. Ideally, if a particular preventive measure would cost less than, say, $5,000 or even $10,000 per QALY, it should be in the first (lowest) co-pay tier. For those that cost more than $10,000 but less than $25,000 per QALY, they could go in a second tier while a third tier could apply to services that cost up to $50,000 per QALY. Above $50,000 but below $100,000, the insured might have to pay the full cost until the deductible is reached, and above $100,000 per QALY, the treatment should be deemed not cost-effective, and doctors should be discouraged from using it unless the patient wants it and is willing to self-pay. Policymakers could decide on the real numbers that they think make the most sense from both a health and an affordability standpoint. Mine are just illustrative of how I would approach the issue conceptually.

  20. Thanks to many of you joining the conversation–
    First, on foreign doctors in the U.K. and in the U.S.
    Fully 44% of physicians providing primary care in the U.S. come from medical schools outside the U.S. (This is because American doctors are reluctant to go into primary care but the pay is so much lower than in other
    specialities, and U.S. med students are often saddled with debt. Thus, other countries that provide free or low-cost medical education are subsidizing primary care in the U.S.)
    When you include all specialties, it turns out that 24% of U.S. physicians are from med schools outside the U.S. Fully 24% are from India; roughly 10% are from the Phillippines,etc. This is all from an AMA discussion paper http://blogs.ilw.com/gregsiskind/files/AMA-IMGworkforce2006.pdf.
    As for how many Americans want to go to medical school–surprisingly, only two students apply for each place in U.S. medical schools. This is in large part because med school is so expensive, in part because it is so difficult, in part because you have to have such high grades to get in–and in part, because our health care system is so broken.
    Many,many doctors are very frustrated with how hard it is to try to deliver high quality care in the U.S. Our hospitals, they know, are dangerous places (errors, infections); many of our private sector insurers do their best to delay payment and deny care (which is why doctors prefer Medicare); meanwhile, as doctors and hospitals vy with each other for scarce health care dollars, the competition in a profit-driven system can become vicious. This is why many doctors
    now say that they would not advise their children to go to medical school.
    If we subsidized our med schools in some way (perhaps providing generous scholarships to students willing to practice in parts of the country where they are most needed) we might have a larger and more varied pool of applicants, but if we want to make medicine an attractive profession, we also have to reform the
    Thanks for continuing to find a plan we can agree on. I agree that the cap on a family’s out of pocket expenses–no matter how many children–is very important, and makes your plan much more affordable.
    Let me just ask one question: Am I right in remembering that you originally said that your plan would cover preventive care from the first dollar (perhaps with a $15 co-pay)? And secondly, would regular care and prescriptions for chronic diseases like diabetes, asthma, glaucoma, etc.be considered “preventive care” that patients would receive for a very low co-pay before they paid the deductible?
    If so, then I think we’re pretty close to agreeing on what good insurance means.
    As for taxes in France–it is true that they are much higher, but the safety net is also much more secure in many ways, and the French are very proud of that. Basically, the French feel that nothing is too good for a fellow Frenchman. If only we had such solidarity in the U.S.–it would be much easier to agree on national health insurance.

  21. Dear Mr. Browning,
    Having visited your site I found it to be short-sighted, slanted starboard (I wouldn’t call it right), and nowhere did I find a link inviting comment or discussion. Congratulations on your appearance on Fox News–that bastion of unbiased journalistic integrity. Jolly good show!

  22. Bad people are everywhere, and we best implement safeguards in medicine and food distribution. But I don’t see universal health care as the problem.

  23. “You see, very few Brits these days actually go to medical school. Why? No one wants to work in the NHS. So, the UK becomes dependent on foreign doctors (more than 60% of new UK doctors are from abroad), a few of which turn out to be undetected Jihadists.”
    Gosh… I’ve never seen foreign doctors or nurses here in the US. It must be awful over there!
    And Jihadist doctors too! That could never happen here!
    “Sources: 2 in plot explored U.S. jobs”
    The probe of bomb attempts in Britain has reached Phila., where a certifying agency for foreign doctors has offices.
    By John Shiffman and George Anastasia
    Inquirer Staff Writers
    Mohammed Jamil Asha , a doctor, and his wife, Marwa (right), a medical technician, were among those arrested. With them are his mother and son.
    KHALIL MAZRAAWI / AFP, Getty Images
    Mohammed Jamil Asha , a doctor, and his wife, Marwa (right), a medical technician, were among those arrested. With them are his mother and son.
    Two of the seven doctors arrested in Britain after last week’s failed bomb attacks had explored the possibility of coming to the United States, making inquiries to a Philadelphia-based organization, sources said.

  24. It is nonsensical that one’s employer should be the main source of insurance, and also nonsensical that one should pay exorbitant rates for individual health insurance. Universal health coverage may not be perfect, but it would be many, many times better than our current system (or lack thereof).

  25. Mark Steyn’s take on the NHS is pitch perfect:
    You see, very few Brits these days actually go to medical school. Why? No one wants to work in the NHS. So, the UK becomes dependent on foreign doctors (more than 60% of new UK doctors are from abroad), a few of which turn out to be undetected Jihadists. In fact, probably many more could actually give a hoot about their elderly British patients.
    So, if you want to scare away the best and brightest from the practice of medicine here in the states, by all means go “socialized.”

  26. Maggie,
    A couple of things. First, most current employer plans that I’m familiar with have a family out-of-pocket maximum that is only two times what it is for single coverage, no matter how many children there are. Second, very few people incur $5,000 or $10,000 of healthcare costs every year. Even among the Medicare population, in any given year, 50% of the beneficiaries (21 million people) account for only 4% of the program’s costs according to CMS. If people want to supplement high deductible coverage with a companion policy that would provide complete insulation at a cost of several thousand dollars per year, they can do that. Alternatively, when they experience an occasional high medical cost year, most people in the upper half of the income distribution should have some savings to help cover the costs.
    Suppose, for example, we could provide catastrophic coverage ($5,000 deductible for single coverage or $10,000 for a family) for a 10% payroll tax (split 80-20 between employer and employee) on the first $150K of salary or wage income. To provide first dollar or near first dollar coverage, the payroll tax might have to be 12.5% of wages. While I didn’t mention it previously, we would also need a funding source to cover insurance for the unemployed including retirees not yet eligible for Medicare. I also assume the current Medicare program would stay as is for the current 65 and older population. The question boils down to how much more are we prepared to ask the broad middle class to pay in taxes on top of what they are already paying to achieve universal health insurance coverage? Even the much praised French health insurance system only covers about 75% of costs according to Ezra Klein. About 86% of the population also has supplemental coverage, usually obtained through employers, but a meaningful portion of the population takes care of the other 25% of costs on their own. Moreover, the total tax burden is much higher in France than here which never seems to get much mention from single payer advocates.

  27. Barry–
    400 percent of FPL for a family of 4 is $82,600–Before Taxes. If they live in a state with a state income tax, they probably take home around $58,000.
    If each family member spends $5,000 on healthcare (not hard to do if, for instance the mother has a baby that year, spending $5,000 on herself and $5,000 on the baby, one child has an accident playing sports, another child has asthma and winds up in the ER in the middle of the night two or three times a year etc. . . . . they are now paying $20,000 for healthcare–on a salary of less than $60,000. This is unaffordable, even in regions where the cost of housing is not off the charts
    Doing the math for a single person– 40% of federal poverty level is $40,800–figure $30.800 take home , paying $500 for healthcare . .
    Perhaps some of the items listed above would come under preventive care, and in your proposal, would be covered from the first dollar? Even so, it would be very easy for a family to spend $5,000 per person–especially in areas where specialist’s fees are high. (I spend about $1200 a year just seeing my eye doctor. And that doesn’t include glasses.)
    Finally, research shows that high deductibles (which is really what you are talking about) leads people to defer needed care.

  28. Maggie,
    I’m not sure that I understand your concern about a possible two tier healthcare system under a reform model. Here is a clarification of my perspective.
    First, I assume that money is a constraining resource. Second, if health insurance does nothing else, it must cover the full cost of catastrophic events beyond a reasonable out-of-pocket annual maximum amount. Third, while I don’t have good data on this and, perhaps, you do, my perception is that at least 25% and possibly as much as 30% of healthcare costs incurred by the under 65 population are attributable to the first $5,000 of costs incurred each year.
    I think a reasonable approach might be to provide universal coverage for costs above $5,000 per person to be funded by a dedicated healthcare tax. Everyone would get that, rich or poor. We could fund it with a payroll tax split between employer and employee in approximately the same proportion as current health insurance premiums. Insurers could compete, along with standard Medicare, to offer this coverage and receive either more or less than a benchmark amount depending on the actual health risk of the insured population that they wind up with. They would have to take all comers.
    For the first $5,000 per person of healthcare cost exposure, we could provide sliding scale subsidies to help people with incomes up to 400% of the FPL to acquire this companion coverage which I call the insulation piece. The subsidies would be financed with general federal revenue. The segment of the population with income above 400% of the FPL could buy insurance on their own to cover some or all of the first $5,000 of costs or they could self-insure.
    Whether a given individual opts for standard Medicare or an offering from one of the private insurers, a given insurer’s reimbursement rate to a given provider for a specific procedure would be the same whether the insured is rich or poor or middle income. There would not be any equivalent of Medicaid with its poor reimbursement rates. If it turns out that we can provide the catastrophic insurance piece at a cost we can readily afford, we could always make it more generous later.

  29. Manhattan may have the $$ to support solo practitioners, but in my metropolitan area, they usually can’t survive on their own. Having myself practiced in a group and watched others form and split, most disputes arise not over how one practices but over taking call, vacations, how to split the money, which insurance plan to provide, employee problems, personality conflicts, etc. If you read Sermo you would be reassured about docs asking each other for advice; it also goes on in lounges, hallways, before and after Grand Rounds, phone calls, etc. I just don’t see “autonomy” as the danger or even the definition you do.
    Having said that, I totally agree as I mentioned above that a Mayo or Cleveland structure is best – but mostly because it makes the doctors and hospital work together instead of against each other, and coordinates care better.
    Speaking of Kaiser, here’s where more “autonomy” is needed (unless they’ve changed their ways) – Say Mrs. Jones has a hysterectomy for bleeding fibroids and I, the pathologist, unexpectedly find uterine cancer. At any doctor’s office, but NOT Kaiser, I could call and report this surprising and life-threatening finding directly to the physician who performed the surgery. At Kaiser, I was routinely told, ” (A different) Dr. So and so is taking care of hospital patients today”, or ” Dr. Smith (who performed the surgery) rotated somewhere else this week” – so I would wind up talking to a doc who didn’t know the patient from Adam and couldn’t give me any information about clinical findings and, I was worried, would not accurately relay this critical information where it needed to go. This occurred every day, not just weekends. Ugh!!

  30. I view “autonomy” is the absence of accountability. Maggie’s description of clinicians being able to deviate from guidelines, formularies, etc…but have to document why…and get another clinician to sign off…makes a ton of sense.
    A role of a health insurance administrator playing this role in a cubicle thousands of miles away is what should be (and is) objectionable to many…especially when the administrator has no clinical background.

  31. I think we will ultimately get to a system where the patient sits in front of a computer and answers a lengthy health questionnaire that would then be turned over to the physician for evaluation. But first it would instantaneously search for patients around the country with similar diseases and a list provided of physician treatments and outcomes would be provided. That would allow physicians to remain on their own with at least some feedback from other physicians.
    But I see the days of the solo practitioner as being over. If I were a physician I’d be damned concerned about where healthcare is heading. He who has the gold, rules. And that’s the corporations and they are already establishing their own co-op managed care companies. They should get ready for corporate medicine, because they won’t have another choice in five years.
    Unless out politicians free themselves from insurance company money and establish a Medicare-for-all plan where physicians can remain independent.

  32. Bev–
    The whole hospital building boom is a scandal. In some places, we’re going to have far more beds than we need. We’re definitely going to have more waterfalls, marble lobbies and saunas than we need.
    On “autonomy”– in Manhattan solo practitioners talk about autonomy when describing why they don’t want to be in group practice: “I don’t want someone looking over my shoulder” or “No one is going to tell me what to do” or “I don’t like working with other orthopods.”
    I understand why doctors don’t want to be second-guessed by insurers, but to have a colleague say, “Mark I noticed you’re prescribing X for Mrs.Wilson and I wondered why not . . ” can only help everyone. Given the amount of information out there today, no one docorcan know everything that he feally needs to know . . .
    When I think of collaboration, I think of Kaiser (where doctor satisfaction is pretty high and turnover is low) the Mayo Clinic, the VA and other multi-specialty group practices where doctors are on salary, are not paid fee-for-service, and most importantly, are all looking at the same electronic medical record for a given patient–so they knew what the other doctors are
    prescribing, recommending, etc.

  33. Oh, and Maggie, I think you are misinterpreting the term “autonomy”. Autonomy to me (and I valued it a great deal) means you are not an employee of a corporation who has to please your boss. It in no way precludes collaboration. (And ps, collaboration only works when the whole team is sued for their collaborative action, not just the doctor on the team. Teach the lawyers that before collaboration becomes a meaningful term in health care)
    “Autonomy” as used by physicians today also means freedom from being second guessed by insurance companies in the practice of medicine.

  34. Maggie;
    Are you aware that in the current almost unprecedented boom of hospital new construction/renovation, the vast majority of the patient rooms will be private? Although some cite infection control as a reason, most administrators just baldly state it’s because that’s what the patients want. As I commented in another(I think) blog recently, only our cockeyed healthcare system would lead hospitals to construct private rooms because of demand by patients Who Don’t Pay For The Rooms!!!!!
    You wonks have overwhelmed me with the other stuff. Time to finish the weekend! (:

  35. Matt, Bev, Barry, Jack,
    Matt—I wasn’t suggesting that the “best” or “smartest” students make career choices
    based on money; rather, I was suggesting that AMONG THOSE WHO CHOOSE MEDICINE, a certain percentage make the choice with an eye to how much they
    will make.
    I agree that the fact that many doctors are drawn to the profession because of the autonomy is part of the problem, not part of the solution. That’s what I’ve been trying to say to Doctor K. Virtually everyone who has studied the problems of poor quality in healthcare agrees doctors need to learn to be team players.
    Bev—Your description of why doctors don’t do a better job of policing each other confirms what other doctors have told me. I agree that this must change. Probably the best way to do it would be to set up regional (or state-wide) committees of doctors in a particular specialty to hear cases. It’s important that they only hearing complaints s involving specialists that they do not know (do not work with or compete with). If someone on the committee knows the specialist in question he could recuse himself./herself from the hearing.. Such committees would need legal protection so that they could not be sued.
    And I couldn’t agree more that competition in our healthcare system has become Darwinian—and has helped to breed the “doctor as entrepreneur.”
    Thanks for the link to “I want to move to France.” His experience rings true.
    We need to have guidelines (not rules) for best practice set by specialists in the area—and it shouldn’t be too difficult for a doctor to deviate from those guidelines as long as he
    gets another doctor to sign off (or at least puts his reasons in writing.) This is the way things work in the VA system. For instance if a doctor wants to prescribe something that isn’t in the formulary. If someone is constantly deviating from “best practice” guidelines the VA (or the Mayo Clinic or whoever) will want to know why—patients need to be
    protected from the “I know best Lone Rangers.”
    Doctor K—First, yes I am talking about multi-specialty group practices and secondly, in the many interviews I have done I have not heard of doctors “hiding” in their specialty at places like Intermountain or Kaiser . . . .Doctors talk about collaborating and working with each other.
    As for “one doctor and one patient” having absolute autonomy, most patients will follow their doctor’s lead (particularly if they are very sick and frightened), so in many cases we are really talking about “one doctor” having autonomy. And we can’t afford to have one doctor (or even one doctor and one patient) decide that Medicare (or a private insurer) should pay $300,000 for an unproven treatment.
    Re unnecessary surgeries: I don’t know where you practice, but virtually every heart specialist I have ever talked to says that we’re doing way too many angioplasties and way to many by-passes. No one says “I’m doing way too many” but everyone knows that someone is doing too many—they see the patients. And the most recent medical research suggests that perhaps half of all angioplasties do the patients no good. The same can be said about many treatments for prostate cancer. There is very little evidence that patients who receive the treatments live longer.
    Barry—I completely agree about PSA testing—and other testing .that can lead to unnecessary procedures without reducing mortality or extending life. Have you read Dr. Gilbert Welch’s “Are You Sure You Want to Be Tested For Cancer? Maybe Not And Here’s Why.” He’s up at Dartmouth and has been doing excellent work in this area. He also has published a couple of brilliant op-eds in the New York Times.
    So when it comes to questionable tests, I think that high co-pays are entirely appropriate. And we need to do more to discourage unnecessary tests. (Dartmouth ‘s Center for Shared Decision Making” has some excellent videos and pamphlets outlining the pluses and risks of various elective procedures and tests. After viewing them/ reading them and talking with a doctor, many patients decide not to go ahead with the test or procedure.)
    For most care, I agree that people in the top half of income distribution can afford modest co-pays of $10 to $15. -–though I’m concerned about setting up two tiers of medicine with the best doctors practicing in the top tier.
    I don’t think private rooms in hospitals should be covered by insurance (except in extreme cases—for example, a dying child and her parents should be given privacy, Patients who are in a lot of pain may need their own room. . etc.)
    As for the jalopy/ roller comparison, I think that the difference between driving a jalopy and driving a roller cannot be compared to the difference between having your very sick child treated by a resident or having the child treated by a specialist –depending on how much you can afford to pay. In many states, most specialists in private practice simply won’t take Medicaid patients. They are more likely to get care at an academic medical center but ,there they may only be seen only by inexperienced resident—even if they are seriously ill. .
    Another example—if a child is born healthy, but deformed, should a wealthy child receive the very best plastic surgery while a poorer child receives just what is medically necessary without trying to reconstruct the face as perfectly as possible?
    The fact that some people can afford better healthcare than others is very different from the fact that some people can afford a nicer car. Healthcare is a right, not a commodity. . I’m just not comfortable with “inequities” at the bottom unless we are talking about luxuries (the private room, valet parking, fully body scans for asymptomatic patients, etc.) One reason Medicare has worked as well as it has (and Medicaid has failed) is that
    Medicare is equitable.
    Also, Medicare has done a much better job of containing cost than many private insurers who (since 2000) have been simply passing higher costs along in the form of higher premiums. . You’re right that Medicare wound up costing much more than was anticipated in 1965 (largely because Johnson agreed to let doctors and hospitals set their prices fee-for-service in order to get the legislation passed). But over the last twenty years or so Medicare has been trying to control costs, with more emphasis on outpatient treatment, the $1000 co-pay for hospitalization, etc.
    Finally, while an insurance policy with a $10,000 deductible and a lower premium might well make financial sense for you, or me, or many other upper-middle-class and upper-class people, we need your full insurance premium in the pool to help pay for everyone. . If the wealthy “self-insure” by buying cheaper, high-deductible plans that leaves poorer, generally sicker Americans in the regular insurance pool, forcing their premiums up. We need to take a collective view of health care—to understand that we’re all in the boat together.
    Jack—I agree: in many cases, supply, not demand, drives excessive care
    Barry—Re your hypotheticals::
    First, I have never had a doctor ask me “What is your co-pay on this drug/test? etc. “
    so I have a hard time believing this factors into most doctors’ treatment decisions most of the time. Very likely doctors working with very poor patients in a community clinic might ask the question—or perhaps doctors prescribing very expensive chemo where a 20% co-pay could be unaffordable.
    Secondly, I don’t think insurance should agree to cover a more expensive prescription drug simply because it’s more convenient (1 dose a day instead of 2 or 3). Whether we have a single-payer system or not, this is something that a patient should have to pay for out of pocket.
    Under a single payer system we need to encourage doctors to think collectively, too.
    They shouldn’t order an MRI merely because it “might” benefit the patient. Unless it is an emergency and time is of the essence, they should try less expensive alternatives first (x-ray).
    Under single payer, the ER doctor should be penalized for an unnecessary hospitalization—not just because he is wasting everyone’s money, but because he is exposing the patient to unnecessary risks. Hospitals are dangerous places—especially if you don’t need to be there.
    As for doctors over-treating because they fear litigation, this is why we need more practice guidelines based on unbiased “comparative effectivenss” research that MedPac is calling for.
    Patients who have a cold should see nurse-practitioners, not doctors. And at a certain point, if the nurse-practitioner feels the visits are unnecessary, they should be billed (or sent for counseling).
    Finally, I couldn’t agree more about the need for a “robust mechanism to track utilization by providers and relate it to health outcomes, combined with a system of rewards and penalties for cost-effectiveness and overuse” This is precisely what MedPac wants to do—see its March 2007 report on moving beyond the SGR. I can’t think of a for-profit private insurer that is doing this, except perhaps Kaiser . . .
    Jack and Barry—For various reasons too wonky to detail, it’s extremely difficult to get a handle on administrative costs. Clearly, Medicare has lower costs because it doesn’t have to advertise, lobby or enroll, dis-enroll and re-enroll patients. Clearly, doctors and hospitals would have much less paperwork if there was only one payer (or fewer very good insurance companies who agree on using the same forms while competing with Medicare-for- all). How much lower? I don’t know which is why I don’t tend to emphasize administrative savings when talking about reform.
    But, Barry, Jack is clearly right. Most doctors greatly prefer working with Medicare’s forms. (Medicaid is a whole other kettle of fish since in varies state by state.) Moreover, Medicare pays promptly, while private insurers are notorious for “playing the float” with the money, requiring extra documentation, etc.

  36. Regarding practice patterns being dependent on and changing in accord with patient’s financial responsibility, my views are:
    1. When you bring the dollar bill into the doctor—patient relationship, you adversely affect the relationship. Medical decision making should have as its foundation the “medicine” of medicine and not the “business” of medicine. This is why the doctor—patient relationship has to be the driver of health care expenditure. A single payer (completely funded by everyone living in the USA) will have the ability to control health care expenditure by controlling the prices that are paid for services and product. That way the doctor—patient relationship is left unencumbered by the dollar bill. And the control can be such that good, acceptable (not egregious) profit above and beyond true cost of doing the work can occur for health care businesses. Also, potential financial conflicts of interest need to be removed from doctors’ practices.
    2. Regarding ordering of tests, I think the distinction between information that is “nice to have” versus “absolutely essential” is off the mark. A test result that is “normal” or “negative” may be as much help in further clinical decision making as one which is “positive” for the abnormality that the doctor is looking for. On the other hand, a “negative” result does not always mean that a particular illness is not present. A crystal ball would be nice but I haven’t heard that that piece of clinical equipment is currently available.
    3. A big part of the doctor—patient relationship is Experienced Judgment Grounded in an Extensive Fund of Knowledge. Doctors having this knowledge base is expensive for any health care system because the evaluations become more thorough than they would be without it. I believe that health care business people need to accept this,i.e., deal with the fact that the doctor—patient relationship is the foundation of medical care and therefore the driver of health care expenditure. If you try to influence medical decision making by bringing the dollar bill into the relationship, then you have HMO medicine.
    4. Regarding paper work, my suggestion is to link billing-payment interaction with a single payer to a central storage system for all medical records. I develop this concept in chapter 8.
    Doctor K.

  37. The 31% of insurance bureaucracy waste comes from people who have done a lot more studying of the industry than I, and it is a rather commonly accepted number when you consider that it includes all of the extra billing clerks required by hospitals and clinics to deal with the 1500 insurance companies and likely 50,000 different plans in the nation. But I can readily believe the numbers when I look at the industry’s own administrative costs which include marketing costs, sales brokerage commissions, underwriting, gatekeepers, high executive salaries and high profits enjoyed by shareholders. You can defend the industry all you want, but I don’t know many industries that can operate on 5-7% and still provide all of the above.
    The comparable costs of a Medicare-care-for-all system I expect will be in the range of 9-10%, much like Canada’s, but that will cover 100% of the people for a first class system. And yes, the per-capita spending on Medicare patients is (likely) 2.5 to 3 times that of all other “policies” because they almost exclusively cover seniors that require more care (and the cherry-picking industry would not cover nonetheless), plus the very costly end-of-lifers. But fold in all of the younger crowd and those costs will average out to less than we experience today.
    I’d like to hear from the doctors too, but in my 20 years of billing patients I found Medicare a hell of a lot easier to work with, and with no more paperwork or approvals than the privates. In fact, when you consider the “out-of-plan” difficulties and “gate-keepers” of the private industry, Medicare was a breeze.

  38. Jack,
    I think we might both benefit if a couple of the doctors provide their perspective on how practice patterns might vary if they know that the patient is completely insulated from the cost of care vs the patient having a meaningful deductible and copays to cover. It does not seem like much of a stretch for there to be a difference between (a) this is what I would like to do to be absolutely thorough in treating your issue and (b) since you have a meaningful deductible and copay, there are a couple of expensive tests that I’ll skip. Even though their information would be nice to have, it’s not absolutely essential.
    I really wish you would stop quoting that administrative cost figure of 31% which is just not accurate. Large, self-insured employer plans, which insure about 70 million people, have administrative costs in the 5%-7% range. Typically, such employers pay an insurer between $15-$20 PMPM for claims processing, network access and disease management. Medical costs for a typical employer’s population (and their families) whose age averages about 40 are $3,500-$4,000 per year. Private insurers’ medical cost ratio for commercial customers averages 80% while after tax profits are about 6% of premiums on average. Several percentage points of each premium dollar flows back to the government in taxes. The individual health insurance market, which insures about 17 million people, does have very high administrative costs related mainly to broker commissions and underwriting. However, people who can pass those underwriting screens wind up with comparatively low cost insurance even after paying the high administrative costs.
    Others more expert than I have also shown that Medicare’s administrative costs are significantly understated. Most obviously, since spending on behalf of the elderly is 2.5-3.0 times higher per person as compared to the rest of the population, administrative costs as a percentage of total spending are not directly comparable to private insurance spending on behalf of the younger population. Dollar spending per member per month (PMPM) would be a fairer comparison. Moreover, as I understand it, what Medicare calls administrative expenses is basically what it pays its private contractors for claims processing. It does not include anything for the cost of capital to raise the money it needs to fund its program, nor does it include the cost of its own employees or office rent for the buildings they occupy. A proper and fair analysis comparing Medicare’s administrative costs with those of the private sector would show that they are surprisingly close.
    Finally, the doctors might also want to weigh in on the issue of just how burdensome and time consuming are Medicare’s (and Medicaid’s) documentation requirements needed to get paid.

  39. I don’t think, Barry, even under the best of circumstances, only ordering twice the tests because you have a financial incentive is acceptable. But in my 35 years in the industry I have seen the numbers well above quadruple. But admittedly, even while this greed persists, it is not the major problem in health care. It is an insurance bureaucracy that consumes 31% of healthcare costs without ever laying a hand on the patient. I would rather see that 31% spent on patient care, and a single-payer system will accomplish that.
    Under your scenario #1, there is a much greater issue than can reasonably be discussed here. Is the brand name s new innovation or another me-too drug (where the formula has been just slightly changed to justify a new patent)? Assuming no financial incentive, I’d opt for the MRI over experimenting with any drug.
    Under your scenario #2, if the beds are available remember that the costs are there anyway. Admitting a patient does not substantially increase costs for the hospital, but having lived through chest pain before I’d give the doctor latitude (and a complete family and personal medical history). I think you are too hung up on the value of co-pays, which I think are counter-productive.
    Under your scenario #3, my wife just did all of the above, and she stayed away from the doctor even though she had no co-pay. As a result she is now undergoing treatment for pneumonia.
    I am not sold on your hypothetical scenarios. I prefer to leave these decisions to physicians that have no financial incentive for ordering unnecessary tests, which, incidentally, could be detrimental to a patient’s health.
    Medicare is not perfect, given that politicians have taken millions of dollars in campaign contributions to eliminate the sound rules that Pete Stark pushed through congress in the 1989 Omnibus Reconciliation Act. But nonetheless, it is better than anything we have in the private sector. As I said above, “You get sick, you get care, and the caregiver gets paid. Nothing could be simpler.”
    We agree that MedMal should be replaced with a medical court system, and that we need a robust system for tracking outcomes and utilization. But neither are justification to ignore the massive waste caused by systemic flaws.
    You can continue to claim that “when healthcare is perceived to be free, demand will go out of sight.” But that has not happened inappropriately in any other country, and if it does here there are safeguards that can be implemented later. But let’s not ignore the successes in other countries and shove free-market medicine down the throats of Americans that want a single-payer system.

  40. Jack,
    First, the McKinsey study found that doctors who have a financial interest in imaging equipment are two to eight times more likely to order tests that make use of the equipment, not eight times. However, setting that aside, consider the following situations, both under the current system where the patient has some financial exposure (deductible and/or co-pay) and under a potential single payer system where the patient is completely insulated from out-of-pocket exposure.
    1. You’re a family doctor. You want to do what you think is best for your patients and you want to be thorough. You have no financial interest in any expensive equipment, and you may even be working for a salary. You think your patient may benefit from an MRI, other expensive tests or a brand name drug where a generic exists but the branded drug offers the convenience of a once a day dose vs two or three times a day for the generic.
    Under single payer with no copays, you don’t hesitate to do everything that you think might benefit your patient. If you know the patient has some meaningful out-of-pocket exposure, you may opt for the generic drug instead and hold off on the expensive tests to see if the matter resolves itself or can be dealt with in a less expensive way.
    2. You’re an ER doctor. An insured patient comes in complaining of chest discomfort. Under the current system, you run the blood tests to check the cardiac enzymes. They come back normal. You conclude that the problem is probably indigestion or acid reflux and prescribe appropriate medication. Under single payer with complete insulation and assuming a bed is available, you admit the patient for overnight observation and additional testing.
    3. You’re the patient. You have a cold, sore throat, mild cough, low grade fever, or occasional headache. Under the current system, you decide to see if drinking fluids, getting a lot of rest, or just taking it easy will allow the problem to resolve itself. Under single payer with insulation, you decide to go visit your doctor or, perhaps, a retail clinic for reassurance. After all, it’s free.
    For doctors who genuinely want to be thorough and do what they think is best for their patients, they will drive more spending on behalf of their patients if they know the patient has no out-of-pocket cost exposure than they will if they need to be at least somewhat sensitive to deductibles and copays. Also, our litigation culture and defensive medicine mentality will, at the margin, drive more spending rather than less, again, even if the doctor is on salary and does not financially benefit from the added testing.
    Medicare has done an absolutely miserable job of controlling utilization of healthcare services, and there are meaningful copays and deductibles, including about $1,000 for each hospitalization. When healthcare is perceived by patients as free, demand can approach infinity as doctors will be biased toward additional tests out of a desire to be thorough, not to make money for themselves while patients will demand and expect more.
    Without a robust mechanism to track utilization by providers and relate it to health outcomes, combined with a system of rewards and penalties for cost-effectiveness and overuse, costs will explode to an even greater extent than they already have.

  41. >>> “The primary concern is overuse of the healthcare system if patients have complete or near complete insulation from out-of-pocket costs.”
    Barry, we’ve talked about this before, and I think we have to quit blaming the patient for overuse (though they may be responsible for 20% of it). When physicians invest $150K in an echocardiograph, they damned well better make good use of it, and they do that because (a) they can refer their own patients to it and (b) the tests are profitable as hell when they do so. You recall a while back you referred me to the McKinsey study that showed that physicians who have a financial interest in the testing equipment are eight times more likely to order tests than physicians that have no such conflict. When a doctor tells a patient they should have an echo, it matters not whether there is a co-pay or not. Most are going to do it.
    And I would argue that the smaller the co-pay the (a) less effective they are (if you believe they are effective at all, which I don’t), and (b) the more costly they are to administer (as a percentage collected). If we are concerned about utilization I’d must rather see a no co-pays for the first dozen doctor visits per year, and then a patient facilitator (independent nurse) getting involved to determine if one side or the other are abusing the system, and if so, a co-pay instituted at that time.
    Doctor K, P4P means Pay-for-performance, a concept promoted here and currently being introduced in the UK. However, before we get to that point I believe we need a national database to track outcomes.
    And on unnecessary surgeries, I agree this is less of a problem, though others can probably enlighten that subject with the Redmond CA case (of which I am not fully informed).
    And for those who haven’t seen it, you must. I am not a Michael Moore fan, but in Sicko the message he presents is right on target. Every politician should be required to see it.

  42. Hello. I would like to respond to some of the above comments since my last posting. First, thank you for the kind, courteous reception that you have given to my earlier commentary. I have not been received quite so well on other blogs and web sites.
    Bev: I do not know what P4P means. Regarding resisting price and quality transparency: It would be right in my view if a single payer set standardized fees across the entire country for each type of procedure and for each type of visit. They do not have to be punitive, just controlled and known. I cover this in Chapter 7 of my book. The biggest problem with a veil of secrecy over pricing comes from our hospitals which is another discussion altogether.
    I have no difficulty with NP’s as long as they operate under professional supervision by an employer physician who ultimately bears responibilty for the quality of their work.( Chapter 5) Unless of course the NP takes regular, ongoing night call, pays hefty malpractice premiums, and assumes complete responsibility for a “minor” case that turns out to be not so minor. Their degree of training does not allow them to do this. How do you define “minor?”
    Regarding malpractice, I agree with your comments. See chapter 9 of my book.
    Jack: All financial conflict of interest for example, making money by ordering a certain test needs to be removed from doctors’ practices. I cover this in chapter 7. Regarding surgeries and other procedures performed by physicians, the issue becomes much more difficult. I guess there are some doctors who perform unnecessary operations and non-surgical procedures such as colonoscopy, cardiac catheterizations, bronchoscopy, etc; however, I have never met one. The decision to perform an invasive, risky procedure is not based on financial return for the work in my experience. Maybe others have had different experiences. But remember, that coupled with the risk for the patient from an invasive procedure is the stress for the doctor of avoiding complications and the work of managing the complication if it does occur, not even considering the malpractice litigation stress that often follows. I just haven’t met any doctors who ignore all of this and then perform non-indicated surgeries and procedures solely for financial return. In fact, I think the opposite is often true; doctors avoid doing invasive risky procedures just for those reasons.
    Maggie: The individual doctor—patient relationship is medicine. There is no other way. I do not at all insist on complete autonomy for the doctor. I insist on complete autonomy for the doctor—patient relationship. I am not playing word games here. The decisions made within the context of that relationship require input from two people. No outside agency has the right to interfere with that. I develop this concept in chapter 2. There has to be a standard. In my view the standard is a sound, ongoing doctor—patient relationship for every patient in America. If you have a better one, let me know.
    Regarding your comment about the Bell Curve, I expect you are accurate. Doctors are humans and will fall into the same categories of performance as other groups of humans. Did you expect it to be different? Practice guidelines are okay I guess, but they are made up by people who don’t practice. I would prefer a much higher standard of medical education prior to allowing doctors to enter into practice and then a system of strict, verifiable ongoing education, once they do enter practice. I develop these ideas in chapter 6.
    Regarding your comment about group practices, I again think you are off the mark. First, I do not know if you mean group practices where all the doctors are the same specialty or whether it is a multi-specialty practice. For the former, five of the same type of doctor trying to manage one patient will result in confusion for the patient and loss of continuity for the doctors. There is a whole lot more to continuity than reading over someone else’s progress note.
    For multi-specialty practices, doctors hide within the confines of their specialty, do their consultations, and leave “management” of the case to the primary care doctor who referred them. If the primary care doctor were capable of managing the case, I don’t believe he/she would have made the referral in the first place. I can think of two other reasons for making a referral within a multi-specialty practice: 1. to increase practice revenue. Obviously, I am totally opposed to this. 2. Academic interest. Even though the doctor responsible for managing a patient is doing a good job, if there is a good subspecialist available, a referral might be entertained for a more informed look at the nuances of the disease process. I quite agree with this 2nd reason because it greatly enhances the doctor—patient relationship from both ends. And I think it applies whether the doctor is in a multi-specialty group practice or not.
    Doctor K.

  43. Maggie,
    I appreciate your arguments up to a point, but I have some concerns. The primary concern is overuse of the healthcare system if patients have complete or near complete insulation from out-of-pocket costs. I have moved somewhat toward your viewpoint on preventive care after sitting next to the Chief Medical Director for one of the large insurers at lunch earlier this year. I was surprised to learn that a large percentage of heart patients, for example, stop taking statin and hypertension drugs within six months of starting. Eliminating the co-pay significantly reduced that percentage. On the other hand, not all preventive care saves money. PSA tests, for example, are controversial in this context because they often result in false positives that lead to biopsies and, sometimes, complications. Or, they identify low grade cancers that probably would have never caused any harm in the patient’s lifetime. I also wouldn’t want my tax money paying for full body scans or routine screening of millions of healthy people with no symptoms if the data shows that it’s not cost-effective. I think the AHRQ has some good data on which procedures are cost-effective for which populations and which are not.
    At the same time, I do not think the upper half of the income distribution needs or should have near complete insulation from healthcare costs. Some out-of-pocket exposure is appropriate for them, in my opinion. If we designed a basic benefits package like, say, the FEHBP standard option, the cost should be unbundled into what a call an insurance piece which I define as all costs above $5,000 per year per person, plus the cost-effective preventive care and the insulation piece which would cover the first $5,000 of expenses less, perhaps, a small deductible and/or very modest copays ($10-$15 for office visits and drugs). Everyone could receive vouchers entitling them to buy the insurance piece from the insurer or their choice. We could give means tested, sliding scale subsidies to those up to 300% or even 400% of the federal poverty level (FPL) to help them buy the insulation piece. The rest of the population could buy it out-of-pocket if they wanted it or choose to self-insure.
    In my own case, I incur several thousand dollars of cost each year for prescription drugs and periodic stress tests and other monitoring. On the other hand, since I can afford it and have some appetite for risk, I would be willing to absorb up to a $10,000 per person deductible if such a policy were enough cheaper than the comprehensive plan to make it a worthwhile (to me) risk/reward tradeoff. That also assumes that I would be entitled to contract rates for services within the deductible.
    I’m reminded of a story that Matthew Holt wrote about in response to one of my posts a number of months ago. I had commented that if I were uninsured and suddenly received a voucher sufficient to buy the equivalent of coverage from Kaiser (HMO, closed network, etc.), I would consider myself hugely better off than I was previously even if I knew that wealthy people probably stayed in a private room when they needed to go into the hospital. Matthew related the story of a janitor he knew back in the UK who commented that if a rich guy has a Roller and all I have is an old banger (jalopy in Brit speak), that’s OK. However, if he has a Roller and all I have is a push bike, that’s not OK. I guess at bottom, I’m willing to accept considerably more inequality than you are, though I think everyone should have the healthcare basics including good catastrophic coverage if they suffer a truly serious medical event or have an expensive to treat chronic condition.
    Finally, I’m with you on insurers competing on customer service and trying to find ways to reward the best providers, including paying them higher reimbursement rates. I also would not have any problem with differential copays to help induce patients to use the most cost-effective providers. Moreover, there should be mechanisms that make it considerably easier than it is now to remove sub-standard or persistently high cost providers from the network which, today, is much easier said than done.

  44. Maggie;
    Funny you should mention Hopkins; I spent 2 yrs there as a resident and assisted with teaching labs in the medical school in the early 80’s. I found their medical students to be among the most obnoxious and cut-throat competitive medical students I had ever been around. (I attended med school elsewhere, obviously.) That’s all I’m going to say about that.
    Here’s my theory: the current health care system’s financial and other incentives select, in Darwinian fashion, for the most entreprenurial, business-oriented and (often) therefore less patient-oriented physicians.
    Both my husband and I left practice early because we were not those types of physicians, without going into extraneous detail.
    As far as your numbered points:
    1. See Darwin above.
    2. Ditto; plus many docs do not think the AMA speaks for them. They do us more damage than good, in my opinion.
    3. This really puzzles me. I have been on medical executive committees charged with disciplining doctors so I have some experience. Although most of the committee members correctly recognized when the doctor was at fault, their reluctance to “throw the book” at them seemed to stem from; a) there but for the Grace of God go I and therefore give the guy a break once; b) if we really discipline this person we are causing him/her to lose his livelihood and he has a wife and kids (the latter statement I have heard verbatim), and/or c) he will sue and win so it’s hopeless anyway. It’s not an active effort to protect bad practitioners, but a lack of gazongas (figuratively speaking) to make an active effort to get rid of them. I agree with you that this should change, and fast.

  45. There are a lot of factors that go into choosing a profession…and to think that the “smartest” or “best” students simply follow the money is not correct.
    There are some pretty smart and capable physicists, researchers, philosophers, journalists, etc, etc. who have huge investments in education without the expectation of being paid like a CEO. And there are plenty of CEO’s who have little education. Why are the Service Academies some of the most selective colleges in the nation? It can’t be the $24K per year 2LT salary…or lifestyle “benefits”…
    A big appeal (to many) physicians is the autonomy…and the entrpreneurial opportunities (as small businessmen and women) to make a lot of money…which is more part of the problem than part of the solution.
    There are many incentives in the current system to do exactly what the system doesn’t need: work alone (vs. in a multi-specialty group practive) in a super-specialty (vs. primary care)…and do more complicated procedures (vs. prevent the need for procedures with wellness, etc.

  46. Barry, Bev, Dr. K. and Jack,
    Barry– I think we really only disagree about the role of private insurers. When people talk about giving patients “choices” I become uncomfortable because too often they are talkig about “each according to his pocketbook.” So a poor family winds up with a policy that has a high deductible and co-pays –and as a result, puts off getting needed care. (As you probably know, studies show that people with high deductibles are just as likely to defer needed care as they are to cut back on non-essential care.)
    So assuming that private insurers stay in the game (and I assume the best will, at least for the foreseeable future) I’d like to see guidelines that outline what policies must cover (essentially everything you and I would want for our famlies –something equivalent to Medicare plus Medigap.)
    And I’d also like to see very low (or no) co-pays and deductibles for preventive care and generic prescriptions, and uniform (fairly low) co-pays and deductibles for other procedures.
    Basically, I don’t want to end up with a two-tier health care system. I’m afraid that the lower tier would turn out to be another version of Medicaid–generally low quality, in part because providers are paid poorly.
    If insurers all had to offer both comprhensive coverage and uniform co-pays and deductibles, how could they compete? On customer service and by providing suppport for the doctors and hospitals in their network that would lead to higher quality and efficiency (which go hand in hand.)
    This might mean that insurers would pay doctors and hospitals that had the best outcomes more (measuring outcomes in terms of hospital infection rates, need for readmission, mortality rates, number of days hospitalized for a specific procedure); they might also pay providers more if they install and use electronic medical records, if they can show proof of reducing infection rates, etc. . .
    Bev — I’m afraid I do know students who decided to go to medical school for the money and, to a lesser degree for the perceived prestige. Here I’m thinking of some of my son’s classmates (he went to Johns Hopkins, so knew a lot of pre-meds) as well as students I taught years ago. I remember one student analyzing law school vs. med school after he had gotten into both. On the one hand, he would have to spend more years in med school, but would probably earn ___% more, on the other hand . . Absolutely none of his analysis had anything to do with wanting to help people, finding either the science of medicine or the law interesting, etc. . . I have to say that based on my (purely anecdotal) experience, this is more likely to be true of men than of women who go into medicine. Of course,I’m prejudiced. But female doctors are also much more likely to be in favor of national health insurance, group practice, etc.
    Of course, you’re right, med school and practicing medicine is very hard work–though some doctors make the practice of medicine not so hard, depending on the speciality they choose, the hours they keep, the type of patients they attract (location, location, location), how much they charge and whether or not they take insurance. . .
    In terms of a “comfortable income” Barry’s $150k to $200k sounds about right as a national average. (Keep in mind that this is per person, not per family. If a doctor is married and has a family, probably her/his spouse works too)
    But what is most important, I think, is to reduce the cost of medical education by providing many, many more full scholarships for students willing to work in areas where they are needed for three or four years after med school. I think the benefit–in terms of public health, and the savings (providing preventive care before people become really sick) would justify the cost.
    Jaack– I’d rather do this than reward the top 10% of med students. (Students are already so competitive; I can only imagine what would happen if that kind of reward were hanging over their heads.)
    Doctor K– I agree with many of your proposals–except the emphasis on the individual doctor-patient relationship and the suggestion that the individual doctor should have complete autonomy. This sound a lot like the solo-practioner/ Lone Ranger model of medicine that we have in many part of the country today.
    The problem is that doctors, like electricians and writers, live on a Bell Curve. A few are excellent; the majority are in the middle–i.e. mediocre–and, at the other end of the curve,some are, at best, barely competent.
    This is why we need practice guidelines and why patients are better off when doctors work in group practices where they are looking over each other’s shoulder. (See Atul Gawande’s New Yorker article titled “The Bell Curve”–you can get access by googling it. )
    Finally, Bev, the Health Affairs article sounds very interesring. I’ll look it up.

  47. Doctors should be paid very well; even on par with(honest) CEOs. But not on the basis of how many expensive tests they order or surgeries they perform. I’d like to see some controls on both.
    But we should also reward the best docs, those in the top 10% of their class, with 100% rebates on their educational costs.

  48. Bev,
    Those are very good and very fair comments about doctors’ income.
    The profession, however, has a somewhat arrogant image among a good portion of the public which is attributable, I think, to the following factors:
    1. A general dislike of having their decisions and recommendations challenged. While doctors drive virtually all healthcare spending through hospital admissions, referrals to specialists, writing prescriptions for drugs, labs, imaging, physical therapy, etc., consulting with patients and doing procedures themselves, they generally oppose P4P and resist embracing price and quality transparency.
    2. Through the AMA, they attempt to thwart competition. The latest example: opposition to retail clinics staffed by NP’s and PA’s. These can offer timely access and lower prices for simple, minor problems, but the AMA’s first instinct is to protect what they see as their turf.
    3. A small number of less competent doctors account for a disproportionate share of malpractice. Yet, the profession is reluctant to admit mistakes and often does everything it can to protect its own behind a white wall of silence.
    Bottom line: Doctors do extremely important work and spend a lot of time acquiring the knowledge and training necessary to perform the job. They deserve to make an income adequate to sustain a comfortable living. On the other hand, they could help their own cause considerably if they would (1) embrace price and quality transparency and, through their specialist societies, work to develop P4P metrics that they can live with, (2) embrace competition where appropriate, and (3) admit mistakes and do a better job of weeding the less competent doctors, who account for a disproportionate share of malpractice, out of medicine.

  49. I have read the original essay and the subsequent commentary and I do not believe that the commentators are on the right track. In my view, there is no doubt that the American health care system is in dire need of drastic change. I believe the best way to approach that change is to go back to the basic question of “What is health care?” I believe that health care is simply the doctor—patient relationship. On an individual basis, it is the individual relationship that a patient forms with his/her doctor and through which medical care is delivered. On a nation-wide basis health care is the sum of all these relationships, nothing more and nothing less. I think that you become mired in controversy, greed, politics, profits, annual income, and deal making when you view health care as a business. I believe our health care system needs to be changed to a structure that contains businesses which exist solely for the support of the doctor—patient relationship for every patient in America and not for their own dollar profit. Certainly any business needs good, acceptable profit margins to thrive but, in health care, when the dollar bill becomes the primary focus as opposed to actual health care,i.e., the doctor—patient relationship, we get into the difficulties that we are now experiencing. My new book, EQUAL HEALTH CARE FOR ALL (ISBN13: 978-0-9796994-0-5) available through my web site describes the kind of health care system that I am talking about. It is a system that I believe will achieve the following:
    1. clear and equal access to vital, comprehensive health care for everyone living in America in an affordable manner.
    2. a system which supports good, acceptable profit margins for businesses which operate within our health care system while at the same time removing greed from their modus operandi.
    3. centralized electronic medical record storage.
    4. major advances in handling medical malpractice.
    5. major advances in medical education.
    6. elimination of health insurance companies by a single payer which controls prices of services and products through tough, fair negotiation but maintains good, acceptable profit margins for the businesses involved.
    7. alleviation of employers having to provide a health care benefit.
    8. zero interference from the single payer with the workings of the doctor—patient relationship. This relationship, with zero financial conflict of interest on the doctor’s part, becomes the driver of health care expenditure.
    9. Clear, straight-forward mechanisms of funding that reveal to everyone that health care is not free. Everyone pays. However, no one has to go bankrupt in doing so or to make a choice between groceries and medicines.
    10. other forward thinking concepts and ideas.
    I hope that all the commentators will visit my web site and read my book. I welcome your critiques. I do not have all the answers.
    One final thought: there are several “smoke and mirrors” concepts out there by which various players maintain their very profitable status quo. Some of these are as follows:
    a. Socialized medicine.- a term which has been given a pejorative connotation for over the last century. It is quite possible to have a single payer system that does not ration health care. Also remember my definition of medicine. It is the doctor—patient relationship. We do not have “socialized doctor—patient relationships.”
    b. Cost-effectiveness.- For anyone who wishes to use this term, I want to know what are the units of measurement, how is cost effectiveness determined, and of what clinical usefulness is it within individual doctor—patient relationships?
    c. Market-mediated.- this means maintain the unbridled capitalism,a.k.a., greed that currently exists within our health care economic market place.
    d. Competition drives prices lower.- In my view in health care, competition drives supply that then needs to be filled with increased demand. In health care, for a truly successful system, demand needs to be driven by the doctor—patient relationship. That is simply because health care is not and can not be a business. The last century of trying to make it a business has led to our current system.
    e. and other business jargon buzz words and phrases.
    Doctor K.

  50. Maggie;
    I forgot one thing; regarding the FDA’s deliberation process and evidence-based medicine. Below is an abstract from “Health Affairs”; on making the crucial distinction between EVIDENCE and JUDGEMENT. I was able to read the entire interview under a “access free for 2 weeks” deal, but the full text is no longer available. For anyone who can get it, it is very educational regarding the process of judging evidence in medicine.
    Reflections On Science, Judgment, And Value In Evidence-Based Decision Making: A Conversation With David Eddy
    Sean R. Tunis 1*
    1 David Eddy is founder and medical director of Archimedes Inc. in Aspen, Colorado. Archimedes was founded to improve the quality and efficiency of health care by using advanced mathematics and computing methods to build realistic simulation models of physiology, diseases, and health care systems. Sean Tunis is founder and director of the Center for Medical Technology Policy (http://www.cmtpnet.org) in San Francisco.
    *Corresponding author.
    Evidence-based medicine (EBM) has increasingly influenced decision making in health policy and patient care. Appropriate use of EBM in decision making requires a clear understanding of the distinct “anatomical” components of all decisions: (1) scientific evidence and (2) judgments applied to that evidence by individuals or organizations. In this interview, Sean Tunis discusses these principles with David Eddy. Tunis has provided leadership at the national level in applying EBM principles to health policy decision making at the Office of Technology Assessment, the Centers for Medicare and Medicaid Services, and now the Center for Medical Technology Policy. Eddy is cofounder and medical director of Archimedes; he is widely recognized as a seminal contributor to evidence-based medicine, helping shape the initial ideas and applying them to guidelines, coverage policies, and performance measures. [Health Affairs 26, no. 4 (2007): w500-w515 (published online 19 June 2007; 10.1377/hlthaff.26.4.w500)]

  51. Regarding physicians and income, from my experience there are very few people who go into medicine just for the money. It’s just too damn hard. People forget there are long hours, night call, difficult patients, having to deal directly with death, threat of lawsuits no matter whether you actually made an error or not, worrying about making a mistake and killing somebody, on and on. Income expectation probably does, however, have some effect on chosen specialties, about 50/50 with the medical student’s personality. ( One can practically look at a class and predict the future surgeons vs. internist types by the 3rd year of med school.)
    It’s making an income and then retrospectively having it, or your entire career, threatened that makes us defensive – just like anyone about to lose their job, or take a big pay cut. Doctors are no different than anybody on that score. We are human too.
    If the income expectations were known to be lower before the student entered medical school, I do not think it would be an issue. It’s the transitional generation feeling the pain, and that’s happening right now, despite the popular perception of still-rich physicians all over the place. That may be part of what’s leading to the current perception of doctors treating “just for the money.” I’m not defending it, just observing it.

  52. Maggie,
    I agree that we are not all that far apart. Just as an aside, my view about taxing investment income is clearly a minority position in the industry I work in. I do believe, however, that the mega wealthy, who derive much of their income from investments, should pay at least a similar percentage of their income in taxes as their secretaries do. Their tax burden is considerably lower currently because the tax rate on qualified dividends and long term capital gains is so low compared to rates on ordinary income, and the payroll tax does not apply to investment income either.
    On doctor compensation, I hear you, but I think the key is the definition of how much it takes to “live comfortably.” Whatever that is, it’s clearly a lot more in Manhattan than in Atlanta or Houston. Moreover, if specialists need to spend several years (or more) acquiring the training necessary to become Board Certified in their specialty, their incomes should at least reflect the opportunity cost of the income forgone during that time. Personally, I think family docs in a city with living costs in line with the national average should make at least $150K and probably closer to $200K. Double that might be reasonable for specialists, though billing rates for some might be much higher to reflect very high malpractice insurance premiums.
    My comment about choice referred to choice among insurance plans, not making decisions about healthcare choices. I would like to see plenty of insurance companies trying to differentiate themselves based on customer service, deductibles, copays and scope of coverage with some minimum set of benefits defined legislatively. I also think robust price and quality transparency, along with objective, unbiased infomediaries to help consumers evaluate their treatment options would be helpful as well.

  53. Tom, Medicare may “currently” be unsustainable, but it could easily be dealt with. First by raising the taxation caps on $90K and allow the cap to swing as high as nessecary to pay a good share of the costs. Then by demanding that Medicare negotiate the same 50% discount the VA gets on drugs. Then by demanding that high-tech testing be done in the hospitals and not in clinics where the physicians have ownership in the equipment. And lastly, by not allowing hospitals to be opened and closed willy-nilly and impose caps on the number of, say, MRIs or CT scanners are purchased in an area.
    And Maggie, campaign reform is indeed possible in a way that does not violate the 1st Amendment, and that’s with public funding of campaigns (but on a voluntary basis) as they have in Arizona and Maine. I won’t spend time here but take a look at http://www.wicleanelections.org

  54. Jack, Tom and Barry–
    Jack– I agree. I sometimes think that if we want healthcare reform, first we need campaign finance reform.
    The problem is that campaign finance reform would be
    even harder to pass–for obvious reasons. But I do think that if we (mainstream media, bloggers, etc.) make it clear to the American public just how much power health care lobbyists have–and how they use it (not to promote our health)–more Americans might begin to realize Medicare for everyone really is the simplest answer.
    I agree that Europeans take a collective view of problems while we tend to emphasize the individual. And you’re probably right this is, in part, due to our Calvinist heritage–but also, I think, because historically, “we” in the U.S. have never been under the kind of pressure that, say, the U.K, France and many other European countries faced during World War II.
    Under such circmstances, people learn to pull together.
    But I think that now,the U.S. is facing pressures that we have never had to face before–both economically and politically. This could mean that, at last, we will learn to say “we” instead of “I’ve got mine, Jack.”
    I greatly appreciate the amount of time and thought that you have put into this debate. And you have persuaded me that we are not as far apart as I once thought. This suggests that if more people talked, in depth and detail, about healthcare reform, more of us could come together to find a common solution.
    I agree that the most “doable” solution, at the outset, if for Medicare to take a more rigorous stance about what drugs and devices it will cover. And private insurers would definitely be happy to follow Medicare’s lead.
    You’re right that we need to re-think our approach to end-of-life care. We could learn a lot from other countries about palliative care (which, as you know, does not mean giving up on the patient, or ceasing to treat, but it does mean a) keeping him/her out of pain and b) letting the patient choose whether they want to continue treatment. ) Research shows that, today, in the U.S,. too many patients continue treaments they don’t want becuause they don’t want to disapoint their doctors or “let down” their families.
    On medical student debt–I think that we could make major improvements in our health care system if we fully funded the type of scholarships which we had in the 1970s–scholarships that gave students full tuition in return for agreeing to practice in parts of the country where they were most needed for a certain number of years. (Think of the TV show “Northern Exposure.”) My sister-in-law did this, and wound up staying in the rural area where she first practiced.
    In terms of “opportunity cost”–I tend to disagree in this sense: While you are right, many pre-meds make their decision by comparing how much they could make as a doctor, lawyer, CEO or Indian chief, I really don’t think these are the people we want in the medical profession. It is a profession–not a career you choose based on how much you will make– but something that you “profess to”–i.e., something that you believe in.
    To me, this means that you want to attract future doctors with professional values–people who realize that there is an enormous difference between being a doctor and being a divorce lawyer. You want people who like the work for its own sake–people who would be happy to do it as long as they can live comfortably.
    This really does seem to be the case in counttries like France, and I have a hard time believing that intelligent, hard-working Americans are that much more greedy/materialistic than Europeans.
    Re: paying lower prices for brand-name drugs. The VA formulary really is not restrictive. As you know, the VA has won rave reviews for the quality and efficiency of its care in recent years–despite the fact that its funding has not begun to keep up with the number of paitents the VA is treating.
    Re: financing. I”m delighted that we are in agreement about tax-financing. And surprised that you agree with me about taxing investment income.
    Though I would preferto tax capital gains rather than dividends because I would like to encourage investors to look for dividends–and encourage companies to pay out dividends. Dividends leadsto more stable returns–which is good for retirement savings. And too often, when corporate managment “invests” the money it could have paid out in dividends, it makes very stupid mistakes (mergers based on so-called “synergy,” etc.)
    Finally, I agree that, in many areas “choice is a good thing and consistent with our culture.” But when it comes to healthcare it strikes me that the average layman is not in a good position to exercise that choice. Healthcare is just too copmlicated (not to mention the fact that when you need really expensive healthcare, you are sick, and in many cases, elderly.)
    I think of the Wall Street Journal article that I read a few years ago that extolled the virtues of “consumer-driven healthcare” saying “consumers will be able to pick their hospitals the same way they pick their mutual funds.” Did we learn nothing from the nineties?
    Just as most of us are not in a good position to be our own money managers, most of us are not in a good position to judge whether the healthcare we are being offered is, indeed, based on solid medical evidence.

  55. This is a letter that I have been sending to various public officials and media outlets. It was published in the Northeast Times, recently in Philadelphia, PA.
    Candidates proposing universal health care are inspiring. However, we need
    to fix the health care system as well.
    As a patient and a former employee (I used to work at a famous hospital on
    Long Island) of the health care system – I have first-hand knowledge on how
    the care system works in America.
    Close to 100,000 people die each year in hospitals due to medical errors.
    The hospital I worked at had too much administrative waste. There was
    endless paperwork in processing patient information.
    Many of the positions, especially in the non-medical areas, were filled
    through nepotism. Many of the supervisors and mid-level managers at this
    hospital were concerned about how they looked to top administrators, rather
    then perform thier jobs effectively. (CYA was the major activity).
    A question I would like to ask the general public, particularly doctors –
    How come doctors never challenge other doctors?
    Right after I graduated college I was “confused,” doing drugs, and getting into trouble; so my parents sent me to psychiatrist. The psychiatrist said was I “mentally ill” and he sent me to neurologist for my tests. (Our family doctor stated at first I did not need any tests, and then he changed his mind.) The neurologist examined my brain and said I was fine. I just needed to “grow up.”

  56. dMaggie,
    Good analysis and summary.
    With respect to the so-called waste in the system, I think one of the most doable strategies would be if Medicare takes a more rigorous stance with respect to which new drugs and devices it will cover. For those it deems not sufficiently cost-effective, private insurers probably won’t cover them either. While manufacturers of the drugs and devices, along with some patients who are seriously ill and out of options will protest, somebody has to say no sometimes. The experience you alluded to in an earlier comment regarding the wrath that fell upon the AHRQ when it suggested we were doing too much back surgery some years back suggests that nothing will be easy when it comes to cost control. I’ve said many times that our whole approach to end of life care needs serious reevaluation. A thorough study of other countries’ approach to this issue would probably be instructive.
    I think electronic records is an area where taxpayer funding (or at least subsidies) would be extremely helpful. It might be easiest to start with the hospitals since there are only about 6,000 or so of them, and that is where much of the duplicate testing and medication errors occur because multiple doctors treating the same patient don’t know what each other is doing.
    I’m more skeptical of our ability to reduce specialist compensation except to the extent that we can do it as a by-product of reduced utilization through practice pattern convergence and evidence based medicine backed up with financial rewards for best practices and penalties for over treatment.
    On changing the way medical education is financed, if doctors emerged from medical school debt free, I wonder how much less income they would be willing to accept. If I had the opportunity to not incur $300,000 of debt that would otherwise have to be repaid out of after tax income, I might be willing to accept $30,000 less per year in beginning of career dollars. This would give society a 10% return on the capital that it relieved me from having to invest in myself. This is looking at the issue from an investor’s perspective. I would be curious about how others view it. Doctors’ income more generally will always be strongly influenced by what they can earn in other fields like business and law. That opportunity cost is considerably higher here than in Europe and Canada which helps to account for their considerably higher incomes here than in those other countries.
    As for lower brand name drug prices, the government would have to back up its negotiating with a willingness to employ a restrictive formulary like the VA does. Seniors in particular might balk at that.
    Regarding healthcare system financing, I was actually glad to hear you say that employers would prefer to redirect their current health insurance spending into a healthcare tax. An employer payroll tax is my favorite approach because it is closest to the current system and has the virtue of transparency. I think it is important for people to understand how much they are paying for healthcare, and the more visible the payment, the better. Employer provided health insurance is part of compensation, but many people don’t understand that. The employee could pay a much smaller payroll tax that, as you say, approximates the current employee share of the premium.
    For the seed money to cover the currently uninsured, I support higher taxes on dividends and capital gains. My preference would be to make both qualified dividends and capital gains part of the income base for the purpose of figuring the Alternative Minimum Tax (AMT). For very high income people, the effect would be to raise the current tax rate from 15% to 28%. I think the current top ordinary income rate of 35% is high enough. I note that even under the Clinton tax increase of 1993, it was sold as a top rate of 36% and a temporary surcharge of 10% bringing the actual top rate to 39.6%. The surcharge was to be removed when the deficit was brought under control. The budget went into surplus in the late 1990’s, but, in typical fashion, there was never any effort to repeal the surcharge, which gives rise to the saying “There’s nothing more permanent than a temporary tax.”
    Having said all that, I still would prefer a voucher system to Medicare for All even if it were a bit more expensive. Choice is a good thing and is consistent with our culture.

  57. Good thoughts Maggie.
    > Keep in mind we are spending twice
    > as much as other countries who cover everyone.
    The trouble when you say “we spend”, is that there is no “we”. Well, there is, but people don’t recognize it.
    For most people here, there is only “I” as in “I get health insurance at work” and “I paid FICA taxes all my life” and “I can’t stand freeloaders.” This is the fundamental difference between the (Calvinist) USA and (whether they like it these days or not, Catholic) Europe. Here everything is about personal liberty in the negative sense of freedom from coersion and a presumption of just deserts in life. There, some things are about solidarity.
    Most everything else you have considered is 1980’s style managed care all over again, and that didn’t go so well last time.
    Jack is right, from his point of view Medicare is simplicity itself. But its not sustainable.

  58. This Blog has been an excellent read.
    It never ceases to amaze me, the amount of energy that can go into a project just to avoid doing the right thing. The best, simplest, least costly, most effective thing we could do is expand what has been working so well for years, Medicare. You get sick, you get care, and the caregiver gets paid. Nothing could be simpler. I’ve been on it for four years and it works beautifully.
    But that’s probably its problem. Politicians don’t like “simple” when it affects a major source of campaign cash. Which should tell us that we are getting screwed over in many ways by our corrupt political system.
    To paraphrase a famous quote, “America will always do the right thing, but only after failing at everything else.”

  59. P.S.– It occurs to me that I should make one thing clear: I don’t expect that we can realize the savings from cutting waste in our healthcare system immediately.
    So healthcare reform definitely will need a large amount of “seed money”–but I think that rolling back the Bush tax cuts for wealthier citizens,combined with re-writing the Medicare Advantage law so that we’re no longer paying private insurers a premium to take Medicare patients would do the trick.

  60. Bev m.d., Julia, , Barry
    First Bev, thank you for calling my attention to the Wshington Post story. Everyone should read it–here’s the link:http://www.washingtonpost.com/wp-dyn/content/article/2007/07/05/AR2007070502149.html.
    As it happens I have done quite a bit of research on this drug (an ooncologist alerted me to the problem.) Keep in mind that no one claims that this cancer drug would “save lives” (not even the company). At the very best it will give patients a few extra months of life. At the FDA advisory panel hearing someone asked about the quality of those extra months of life, and the company replied “we didn’t study that.”
    Of course they didin’t. This is a drug for patients suffering from late-stage prostate cancer and the fact is that any extra months of life are likely to be very painful. (In the late stage the cancer often spreads to the bone.)
    I read the minutes of the FDA panel hearing and what was shocking is 1) there were only two postate cancer specialists on the panel (they both voted against hte drug 2) when others on the panel began to vote against the drug the FDA’s representative on the panel re-worded the question–to get positive responses.
    I plan to write about Provenge on tpmcafe.com in the next day or two.
    This drug is an example of the cruel waste that Julia talks about. And when she says “at what cost?”–she is right; getting Medicare and private insurers to pay for drugs like these is not just a waste of money. Such drugs also raise false hopes and expose patients to needless suffering.
    Thank you, Julia for your comment–it illustrates the problems perfectly. I too wish Moore had focued on waste, but he was trying to make a film for a large audience that knows very very little about healthcare. It’s easier to explain to them first that, even if they have insurance, they may not get the care they need because their insurance doesn’t cover a lot of things.
    Then, someone should make a second film showing how if you have very good insurance, there is a real likelihood that you will be overtreated. This is a harder idea for people to grasp. For decades we have been brainwashed into believing that more care is better care, that newer is better, that any so-called “advance” in medical technology is a miracle . .
    So it’s going to take some re-educatoin to get people to realize that we have two huge problems: while some people (who are uninsured and UNDERinsured)don’t get the care they need, other people (who are well-insured or are on Medicare) often are over-treated.
    Barry–Many of your questions come down to cost: how much would universal care cost and who is going to pay for it?
    Here’s my short answer: if you look at the waste in our system, and if you look at the fact that we spend roughly twice as much as other developed countries who provide as good and often better care to all of their citizens, it seems pretty clear that we don’t have to spend More to cover everyone. We need to spend what we are now spending MORE WISELY.
    If we refuse to spend twice as much for drugs and every device if we refuse to cover drugs, devices and treatments until there is solid medical evidence that they are better than what we already have; if we use some of those savings to invest in the electronic medical records that would eliminate many medication errors and many redundant tests, if we took an unbiased look at the fees Medicare now pays the highest-paid specialists and took some of that money to raise fees for family docs and internists who provide preventive care (something that Medicare is already planning on doing) . . . the savings would allow us to give everyone the care they need. We could provide care equivalent to what both Medicare and what Medigap policies cover.
    Keep in mind we are spending twice as much as other countries who cover everyone. If they can do it on a shoestring, why can’t we do it while spending twice as much?
    How would we finance the system? Big employers have already made it clear that the majority would rather spend what they are spending today on employee health insurance and pay it in the form of a tax that goes into a federal healthcare fund. Individuals could be taxed,on a progressive basis,so that the average middle-class American spent roughly what he spends today in health care premiums and deductibles. (I’d suggest taxing both earned income plus a small tax on capital gains.)
    Hospitals that say they couldn’t afford to take Medicare rates from everyone are lying. Most private insurers don’t pay that much more than Medicare–as you know, private insurers negotiate as hard as they can for disounts. Medicaid, on the other hand, does pay significantly less than Medicare and insurers, but udner national health insurance, most reformers want to fold Medicaid into Medicare and pay the same rates.
    The biggest fiancialproblem that hospitals have is uncompensated care. Under national health insurance, there would be no unpaid bills would have insurance to cover everything that is medically necessary. . The only hospitals that would be “losers” are those that now provide very little charity care.
    Would we stifle innovation? No. First, drug-makers spend about twice as much advertising, PR, focus groups , lobbying, etc. as they do on research. Much of the most innovative reserach today is done by the govt-(and by small companies) -not by big Pharma. (See Dr. Jerry Avorn’s excellent book “Powerful Medicines” on all of this.)
    Secondly, much resarch shows that when it comes to “bleeding edge” innovation by drugmakers and device-makers, we’ve reached a point of diminishing returns. We made great strides from the fifties up to the mid-nineties; since then we’ve had very, very few real “break-throughs.” See for example: “Is Technological Change In Medicine Always Worth It? The Case Of Acute Myocardial Infarction by
    Jonathan S. Skinner, et. al. in Health Affairs. Here’s the abstract
    ” We examine Medicare costs and survival gains for acute myocardial infarction(AMI) [heart attack victims] during 1986–2002. As David Cutler and Mark McClellan did in earlier work, we find that overall gains in post-AMI survival more than justified the increases in costs during this period. Since 1996, however, survival gains have stagnated, while spending has continued to increase. We also consider changes in spending and outcomes at the regional level. Regions experiencing the largest spending gains were not those realizing the greatest improvements in survival. Factors yielding the greatest benefits to health were not the factors that drove up costs, and vice versa.
    Finally, would some people decide not to become doctors (or retire early)if they thought they wouldn’t make as much money as in the past? Most likely. And we’d be lucky to lose them. We don’t need more physicians who go into medicine for the money. These are the folks who are driving up costs with their overtreatment Let them become lawyers.
    When managed care became popular, people realized that doctors salaries would flatten out–and medical schools say that they saw a change in who goes into medicine (more women, for one) and by and large they see it as a positive change.

  61. Barry;
    Well, you almost had me persuaded that there remains a role for profit-making in health care. Indeed, in our capitalist democracy, it seems there is no stronger method for achieving real advances than the profit incentive.
    That was until I woke up this morning and read an article in the Washington Post citing two oncologists who are in physical danger after advising the FDA there was not enough evidence to approve an advanced prostate cancer treatment – not just from desperate patients, which may be understandable – but from INVESTORS in the biotech company making the drug. ( See washingtonpost.com, front page.) This is a dramatic, but predictable, escalation in the medicine-by-intimidation world brought to us by the profit-makers.
    This behavior is completely unacceptable.

  62. Maggie:
    You make some excellent points here – especially about the waste in American healthcare.
    As I watched SiCKO, I felt a great deal of empathy for the people in the film, since my late husband Tim and I were also victims of this failing system. Tim’s brain tumor was diagnosed in 1990, and even with our non-HMO, “Cadillac” insurance policy, we were shocked to discover that we were definitely NOT completely covered.
    In fact, we were left nearly broke.
    But during this time, I witnessed so many instances of both substandard treatment and terrible waste.
    Substandard treatment and waste are things Michael Moore never mentions in SiCKO. As a matter of fact, on both Larry King’s and Dave Letterman’s shows, he said that we have wonderful healthcare in this country; it’s just that too many people can’t afford it.
    This, those of us who have dealt with the system know, is simply not true.
    My husband and I saw lots of medication errors, a real lack of caring on the part of both doctors and nurses, and all-around sloppy care. I wrote about this is my review of SiCKO on my HonestMedicine.com blog.
    And you hit the nail on the head when you wrote about how our system wastes money. As I watched the segment in SiCKO about the man who was denied a potentially “life-saving” bone marrow transplant, I asked myself: “Would the transplant have given this man just a few more weeks of life? And if so, at what cost?” And when I mention cost here, I am actually referring to the pain and stress of an incapacitating surgery — NOT the financial cost.
    My husband endured numerous rounds of debilitating chemotherapy for his brain tumor. It was only after he was finished with his treatments that I did some research — and discovered that the chemo most probably did not even cross the blood brain barrier!
    Was this care — or waste? It certainly was unpleasant.
    In the film, Moore suggests many times that chemotherapy is a “life saving” treatment. I wish he had read some of the articles and blog comments, both here and on the Healthy Skepticism website about the Chemotherapy Drug Concession, which allows oncologists to make a hefty profit from the chemotherapy they deliver. (Please see Greg Pawelski’s take on the situation on this blog at https://thehealthcareblog.com/the_health_care_blog/2005/04/pharmaphysician.html, and on the Healthy Skepticism website at http://www.healthyskepticism.org/news/2007/Jun.php .) Even MSNBC wrote about the chemo concession. (See http://www.msnbc.msn.com/id/14944098/ ).
    And one important study, “The contribution of cytotoxic chemotherapy to 5-year survival in adult malignancies,” published in December 2004 in “Clinical Oncology,” concluded that “the overall contribution of curative and adjuvant cytotoxic chemotherapy to 5-year survival in adults was estimated to be 2.3% in Australia and 2.1% in the USA.” And: “it is clear that cytotoxic chemotherapy only makes a minor contribution to cancer survival. To justify the continued funding and availability of drugs used in cytotoxic chemotherapy, a rigorous evaluation of the cost-effectiveness and impact on quality of life is urgently required.” (See http://301url.com/cytotox .)
    I wish Michael Moore had read these articles and studies before he made SiCKO.
    Yes, waste is a terrible problem in American healthcare, and it won’t disappear as long as so many physicians are in the thrall of Big Pharma — something this blog has written about many times. I cover this problem of physician’s financial ties to pharmaceutical companies more fully in both my review of SiCKO at http://www.honestmedicine.com/2007/07/michael-moores-.html, and in my 3-part article, “The JAMA Controvery,” at http://301url.com/jama-all .
    I want to stress that I am NOT for insurance companies and HMOs saving money at the expense of patients. I am just not a fan of physicians telling their patients that a treatment is “life-saving,” when it may simply be lining their own pockets.
    Again, thanks for your excellent take on this problem. I hope I have added something to the conversation, as well.
    Julia Schopick

  63. Matt, Matthew Holt, Bev and Barry–
    Matthew–Can I be in the room too? (Don’t mind getting shot as long as you stipulate that we will come up with the best solution.)
    Matt- I do think that the cost of Med School in the U.S. has a lot to do with why our doctors feel they need so much higher salaries. The other factor is that CEO compensation in the U.S. has spiralled to an obscene point–and now defines wealth.
    Doctors compare themselves to CEOs. As one doctor said to me– “I spent a longer time in school than they did. I’m much smarter than most of them are– so why are they paid so much more?” When doctors read about CEOs’s earning $7 million, they feel very dissatisfied with a salary of , say, $500,000 to $700,000.
    But the biggest problem, I think, is the cost of medical school. Surprisingly, there are only 2 applicants for every place in U.S. med schools–in large part because the debt that most med students take on narrows the field of those willing to apply . Unless you’ve come from a pretty wealthy family, the idea of taking on that much debt is just overwhelming. (If you’re from a wealthy family, your parents may well pay for you–or assure you that they will help you in the future–with a downpaymet on a house, an inheritance, etc.)
    And because med school is so expensive, very few students are willing to become family docs . In other countries, the income gap between specialists and general practitioners is much, much less.
    Bev and Barry–I’ll reply tomorrow

  64. “I think we are better off if we preserve as much choice as possible and a strong role for private insurers.”
    Same system as we have now, no change. Just what the present profit takers want. Ever heard the song “Waist Deep in Big Muddy”, by Pete Seeger?

  65. “4. To the extent that doctors’ income is squeezed further, we could, over the intermediate term, see an acceleration of retirements and, longer term, a decline in the quality of people interested in becoming a doctor.”
    It’s not as if there’s not widespread discontent among physicians with the current healthcare non-system…even with physician income ranking as the highest among all jobs in the US, what percentage of physicians would recommend medicine to their children?
    Other countries seem to maintain an adequate supply of physicians (especially primary care) and clinicians of high enough quality to result in superior health system rankings…while paying them much less than in the US. What can we learn from others?
    If being a physician didn’t bring with it an expectation of massive medical school bills and accompanying income, would enough Americans still want to be doctors? Would the “new generation” of docs be different than the last?

  66. I’ve often said that if you put Barry, me and Eric Novack in a room together and locked the door until we were done, you’d eventually get a plan that would solve most of our problems.
    Of course we’d be shot on the way out of the door!

  67. Maggie,
    I appreciate both your detailed response(s) and your patience.
    Here is my perception of what advocates of single payer / Medicare for All see as the benefits of that approach:
    1. Universal and guaranteed coverage. Can’t be taken away. No link to employment. One pool.
    2. Lower administrative costs.
    3. Lower reimbursement rates for doctors, hospitals, drugs, devices, etc. based on market power.
    Here are the issues that trouble me:
    1. There has been no effort to speak to how such a system would be financed. Whether it’s via a payroll tax, value added tax, higher income taxes or some combination of all three, how would the broad middle class be impacted vs what they are paying now? Moreover, to the extent that such a system envisions much higher taxes on upper income people, it does not speak to the potential adverse impact on investment and risk taking.
    2. Administrative cost savings are almost certainly wildly overstated. All of the rhetoric regarding the administrative waste in the current system is grossly exaggerated, especially as it relates to large employers.
    3. Medicare can get away with cost shifting to the private sector under the current system. It could no longer do that if it covered everyone. Hospitals in particular claims that they could not continue to deliver services to the same quality standard if they had to take Medicare rates from all comers even if there were no uncompensated care.
    4. To the extent that doctors’ income is squeezed further, we could, over the intermediate term, see an acceleration of retirements and, longer term, a decline in the quality of people interested in becoming a doctor.
    5. The government has proven itself totally incapable of controlling costs or utilization of medical services. The early predictions of what the Medicare program would cost were way off base (far too low).
    6. It is difficult for government programs to innovate and respond to changes in technology. I note that it took Medicare 40 years to get Congress to enact a prescription drug benefit which was an unimportant issue when the original legislation passed in 1965 but became far more important later. I also note that Medicare requires a deductible of at about $1,000 for each hospitalization and a 20% copay for Part B services with no out-of-pocket maximum. Many seniors cannot afford a supplemental policy to cover most of these costs which partly explains why Medicare Advantage is increasingly popular.
    I think we are better off if we preserve as much choice as possible and a strong role for private insurers. I’m more than willing to accept somewhat higher administrative costs to accomplish that.
    As you, I, and others have pointed out before, Medicare also has a lot of work to do in the areas of evidence based medicine and comparative effectiveness. Some soul searching by the society with respect to end of life care, along with malpractice litigation reform (health courts), implementation of electronic medical records and much more robust price and quality transparency would all contribute toward reduced utilization and less waste.

  68. The story from Bloomberg (I wondered what ever happened to Av Goldstein after he trashed the hospital where I used to practice in the Washington Post in 1999) sounds like those Homeowner’s Warranties that sellers advertise as conveying when they sell a house – they sound good but don’t actually pay for anything when you need it. They would cover a bad auto accident (which IS a significant cause of mortality/morbidity in this age group) but that’s about all.
    Barry, I am the one from Paul Levy’s blog who thinks you should be on the committee to reform health care. (: However, in this case I have to agree with Maggie; the insurance companies are NOT out to cover sick people; you have been lucky with your health problems because, no doubt, you work for a company which provides Cadillac insurance. I am in the individual market which, as you note, is a mess and getting worse.
    If you had your health problems in that setting your premiums would be out of sight by now. Count your blessings, but don’t expect them to extend very far. I believe employer-sponsored insurance is a losing cause. Beyond that, I do not have enough data to know what’s best – except (soapbox again), we need to fix the delivery system first, then the payment system, or at least concurrently.

  69. Matthew, Eric and Barry . .
    Matthew–thank you. And do see the movie!
    Do you know how to Google? I hate to sound testy, but it does make me grouchy when someone treats me like a human encyclopedia asking me: ?when you look at total revenues [at Mayo and the Cleveland Clinc], where do the dollars at those institutions come from? and, more specifically,[can you] break down the average revenue per patient, based on how they are paying (i.e. private insurance, medicaid, medicare, cash paying domestic and foreign)…??
    Nevertheless, I did a little reserach and in short this is what I discovered: Although many people assume that the Mayo Clinic mainly treats wealthy people (many of them from abroad), the truth is that nearly 80% of its patients come from the 5 states closest to Rochester,Minn.–and more than half come from a 120-mile radius.
    Many are ordinary people. Some are uninsured. If they live in Minnesota and earn less than $125,000, Mayo gives them a discount. In addition , last year Mayo provided $214 million in unreimbursed care (charity care and care for Medicaid patients that wasn’t fully paid for) against $5,300 million that it took in as revenue for medical services.
    Bottom line: If we had Medicare-for-all Mayo would have made an additional $214 million.
    In addition, many private insurers refuse to cover Mayo (because it won’t play ball give them big discounts) or they make customers pay higher premiums if they pick a “tier” that includes Mayo. If we had Medicare -for- all, Mayo would not have to deal with this problem. (Medicare pays all providers in a particular geographic location the seem rates–it does not play the discount game.)
    Medicare for all also would mean that Mayo (and other hospitals) could save a fortune in paperwork. Rather that filling out dozens of different forms for dozens of insurers, they would deal with one form–Medicare’s.
    Finally, as to the Cleveland Clinic–last year the cost of unreimbursed and charity care went up 5.6%–which suggests that they, too, could use the fiancial relief that would come with everyone being insured.
    On employer-based insurance– employers are voting with their feet. As the WSJ reported in April: “Sure nearly 60% of Americans still get health insurance on the job. But even in a growing economy with a tight labor market, employer coverage is eroding. Fifteen years ago, says Joseph Antos of the conservative American Enterprise Institute, ‘large employers were concerned about rising health spending, but they were not leading the march to a big solution.’ Now they want out.”
    On what Wall Street wants. As you point out pension fund managers are a separate breed: they take the long view. But the pages of papers like the WSJ would not be filled with quarterly earnings estimates if most money-managers (and their clients) thought that way.
    As to whether investors want insurers to avoid providing needed coverage in order to save money, see the recent story from Bloomberg cut and pasted below. It is a largely positive story about how insurers are beginning to make money selling cheap policies to young people that avoid certain potentially expensive and risky areas–like maternity benefits. As we all know, many young women don’t plan to get pregnant–but do anway, and often then decide to go ahead and have the baby. Without maternity benefits will they get appropriate pre-natal care? Is it good national health care policy to sell insurace policies that don’t include maternity benefits to young women of child-bearing age?
    While the Bloomberg story includes a few lines of caveats toward the end (“critics say”) this is a story written from the point of view of investors who will be happy to hear that insurers are finding a new source of profits . . .
    WellPoint Seizes Lead in Cheap U.S. Health Insurance (Update1)
    By Avram Goldstein
    June 14 (Bloomberg) — Aetna Inc. and WellPoint Inc. are competing to sell no-frills health plans to a generation of so- called young immortals, Americans ages 18 to 34 who don’t have medical insurance because they doubt they’ll need it.
    Aetna, WellPoint and about 160 other U.S. insurance providers see future sales growth in these 19 million young adults. The companies are offering policies with monthly premiums of $39 to $160, hundreds less than other plans. Insurers keep costs low by requiring customers to pay as much as $5,000 of their medical bills before coverage kicks in.
    WellPoint, the top U.S. provider of individual health plans, may gain the most from the expanding market. Young adults are the fastest-growing segment of the 45 million Americans without medical coverage. If everyone in the group bought a policy, insurers would gain $25 billion in annual sales, said Sheryl Skolnick, an analyst with CRT Capital Group LLC.
    “I don’t know how any self-respecting, for-profit, shareholder-owned company can leave that kind of market share and profit on the table,” said Skolnick, in Stamford, Connecticut.
    The companies pitching plans to young adults include UnitedHealth Group Inc. of Minnetonka, Minnesota, the largest U.S. insurer; WellPoint of Indianapolis; Aetna, of Hartford, Connecticut; and the San Francisco-based nonprofit Blue Shield of California. Philadelphia-based Cigna Corp. and Medica, a Minneapolis-based nonprofit, plan to join the competition.
    Health Insurance Stocks
    While health insurance stocks haven’t increased yet from the young immortals market, the record of the insurance broker eHealth Inc. of Mountain View, California, suggests they may. Shares of eHealth have gained 30 percent from an initial public offering in October through yesterday. The shares fell 45 cents, or 2.5 percent, to $17.83 at 9:42 a.m. New York time in Nasdaq Stock Market composite trading.
    EHealth says it sold $36.1 million in policies to the age group in 2006, 59 percent of its revenue, up from $23.8 million, or 57 percent, the previous year.
    Shares of medical insurance providers have risen this year from expanding sales of private plans sponsored by Medicare, the U.S. health program for the elderly and disabled, said A.M. Best Co. analyst Sally Rosen. Revenue for publicly traded health insurers increased 31 percent in 2006 to $225 billion, she said.
    The six-member Standard & Poor’s 500 Managed Health Care Index rose 22 percent in the 12 months through yesterday. UnitedHealth increased 17 percent; WellPoint, 15 percent; and Aetna, 29 percent. All three are rated “sector outperform” by CIBC World Markets analyst Carl McDonald.
    Shares of UnitedHealth fell 22 cents to $52.89 at 9:43 a.m. in New York Stock Exchange composite trading. WellPoint shares rose 45 cents to $81.82, and Aetna shares fell 21 cents to $51.23.
    WellPoint’s Lead
    WellPoint has the most at stake in selling policies to young people and is using Internet ads to sell its low-cost Tonik- branded health plans to them. Through its ownership of Blue Cross-Blue Shield plans in 14 states, the company has 2.5 million individual policy holders of all ages, compared with UnitedHealth’s 700,000, Aetna’s 240,000 and Humana’s 190,000, according to estimates by analyst Brian Wright at Jefferies & Co. in New York.
    Insurers don’t break out sales to individuals in reporting earnings and declined to provide the information.
    From 2000 to 2005, individual health policies sold to young adults increased 6.2 percent to 3.8 million, based on U.S. Census data, while the number of people without coverage climbed 24 percent.
    Insurance providers need the young individual customers to provide new revenue as employers cut back on purchases of group policies, the industry’s main source of profit. The proportion of Americans covered by their companies fell to 59 percent in 2006 from 63 percent in 2000, according to the Kaiser Family Foundation of Menlo Park, California.
    Group Insurance Shrinking
    “Insurers would much rather be in the group insurance business, but it’s been drying up,” said Jonathan Gruber, an economics professor and insurance expert at the Massachusetts Institute of Technology in Cambridge.
    Health insurance providers are also “trolling for new business” to prepare for a time when the U.S. government or states may encourage or require that everyone have coverage, said analyst Rick Byrne.
    “It’s going to take a government mandate to move the individual market,” said Byrne of HealthLeaders-Interstudy, a managed-care research firm based in Nashville, Tennessee.
    President George W. Bush has encouraged enrollment in tax- free health savings accounts that enable people with high- deductible health policies to set aside money to pay their out- of-pocket medical expenses. Enrollment in the plans hasn’t grown at the pace Bush envisioned.
    Consignment Store Worker
    Robert A. Nielsen, 25, works in a Salt Lake City consignment store that doesn’t offer a health plan. He was uninsured for a year and a half before buying a policy seven months ago from the nonprofit Regence Group of Portland, Oregon.
    “I’ve been meaning to get to it for a long time, and finally just enough fear and concern caught up with me,” Nielsen said in a telephone interview
    An online search led him to a policy with a $91 monthly premium, a $1,000 deductible and a $3,500 annual limit on out-of- pocket expenses. Nielsen pays $5 for generic prescription drugs and 25 percent of the price for brand-name medicines. An emergency-room visit would cost $75 plus 20 percent of the bill after Nielsen satisfies the deductible.
    Marketing to young adults will make a new generation familiar with health insurance, industry executives say.
    `People We Need’
    “They’re exactly the people we need in the insurance pools,” said Bob Hurley, spokesman for eHealth, in a telephone interview. “Their money supports those that have higher health care needs.”
    The key to success is avoiding the sickest customers and accurately estimating claims payments to doctors and hospitals.
    “These plans can be pretty profitable if underwritten correctly” because the health risks of young people are fewer and can be more reliably predicted, said Thomas A. Carroll, an analyst with Stifel Nicolaus Capital Markets in Baltimore.
    WellPoint has introduced its Tonik line of insurance for young adults in six states since 2004. Five states will be added this year.
    The company’s Tonik Web site has pop-art images of young people, including a woman sticking out her pierced tongue, and marketing slogans that jump and blink against backdrops of cobalt and chartreuse.
    “What you say and how you say it is almost as important as the benefits” in marketing to young adults, said Jude Thompson, WellPoint’s president of business for individuals under 65.
    In California, WellPoint sells Tonik policies called Thrill- Seeker ($77 a month with a $5,000 deductible), Part-Time Daredevil ($87 with a $3,000 deductible) and Calculated Risk- Taker ($106 with a $1,500 deductible.) In addition to major medical coverage, Tonik provides dental, vision and generic drug benefits and several doctor’s office visits a year. Maternity benefits are excluded.
    Tonik inspired WellPoint to plan similar marketing aimed at Latinos and retirees who are too young for Medicare, Thompson said.
    Critics say the policies do more harm than good, making it more difficult for the U.S. to find ways to cover older patients.
    “At the end of the day, what have we achieved?” said Chris Jennings, who was senior health policy adviser to President Bill Clinton, in a telephone interview. “These companies are solving the problems of the healthy.”
    To prevent such “cream-skimming” of the least risky patients, insurers should be required to set prices for individual policies solely by location, not age, said Bob Laszewski, a Washington health policy consultant.
    Higher in New York
    That’s the law in six states including New York. As a result, monthly premiums in those states are higher. One plan sold in New York City starts at $256 a month, without drug benefits, according to eHealth.
    By contrast, John Rael, a 24-year-old actor in Hollywood, California, pays $120 a month for a WellPoint plan with a $1,500 annual deductible. He said it’s worth the money because he doesn’t feel immortal.
    “With a certain injury, you could be $50,000 in debt instantly,” said Rael. “We’re all kind of one step away from total disaster.”
    To contact the reporter on this story: Avram Goldstein in Washington at agoldstein1@bloomberg.net .
    Last Updated: June 14, 2007 09:48 EDT

  70. > I guess all the interviews and TV appearances…
    Browning has here changed the subject. Typical.
    Browning said Moore in the film advocates abolishing private insurance. He doesn’t. Browning has read his own prejudices into film, and so I have good reason to think he has read them as well into all the interviews and TV appearances.
    Dr. Novack, you say Moore supports legislation of the “type” sponsored by Sheila Keuhl. What is the discriminator of type for Moore? Do you know?
    I have read the language of the bill here and have not seen any provision making private payment illegal, but for now I will take your word for it that its there. If this provision were removed, would it be for Moore a different “type” of legislation? How about for you?
    FWIW, I think its a poor bill containing a great deal of stupidity and a non-starter to boot. I think its being floated as a way to beat up on industry evildoers, not because anyone thinks it has a realistic chance, or is a particularly good idea. It ought to be rejected, and in the end I think it will be. But it will get people talking — its the legislative equivalent of a Michael Moore film.

  71. Thanks to Maggie for a great review and to all for an interesting discussion.
    I still haven’t seen the movie, but hopefully will soon. However, it’s clear that Canada and Cuba are exceptions here in that there is no private insurance to help you jump the queue. In the UK there is, and as one commenter points out, it helps certain specialists make a very nice lifestyle on the side from their NHS jobs, and acts as a release valve so that richer people don’t have to wait in the queue.
    However the key point about all those systems is that you can restrain overall costs and cover everyone in some form of social insurance pool without forcing the “do I pay to have my finger reattached” decision on patients at the point of care. That’s the crucial difference, which even if Moore doesn’t make it too clearly is the point that needs to get out to the public.

  72. Tom– read the actual language of Sheila Keuhl’s bill, and the mirror legislation in Arizona (HB 2677)— this is the type of ‘reform’ that Mr. Moore purports to support.
    Private insurance- beyond that– privately paying for ‘covered services’ (which as Peter has implied can be attributed to nearly everything but purely cosmetic surgery) is against the law. That is not interpretation of the bill– the langauge is directly there.
    Maggie- would you address my basic questions posed earlier in the comments? thank you.

  73. Tom, That’s news to me.
    I guess all the interviews and TV appearances in which he has recently advocated outlawing private insurance were not broadcast in your parallel universe.

  74. Do we really care what Michael Moore advocates? C’mon boys, let’s get on issue.

  75. Stuart Browning writes:
    > In [SiCKO], Moore advocates
    > abolishing private insurance.
    Nonsense. Browning here is inventing a “fact” to use as a premise in another of his specious arguments.

  76. Bev- I would like to defer the question to Ms. Mahar, who, I hope has some good idea since she touts those institutions as the paragon of medical care…

  77. Joe Blow;
    I was actually referring to the Cleveland Clinic in most of my comments above, including the observation regarding having an ER. (I really don’t know much about the Mayo except generalities.) I imagine the situation in Cleveland is different than that in Rochester. Again, however, I have no data on how busy the Cleveland’s ER is.
    Dr Novak;
    I do not know the answer to your second question. Do you? The point I was trying to make is a plea to not take competition out of the equation, however one chooses to pay for it.

  78. A redirect to Maggie ( I am appreciative of the time you took to read my comment) on Porter and Teisberg’s suggestions about sending patients to only the best providers-
    I seem to recall, and I’ll watch for the citation as I read through their tome for the 5th time, that they were suggesting that by having a higher authority (a body modeled on the Institute of Medicine) mandate that all providers look to the results achieved by the superior providers and mimic, imitate, follow, in short, learn from those experts, through published results, then every one who is constitutionally unable to learn, or won’t or can’t will need to retrain, find another field or retire, hopefully making room for the better motivated, happier newly initiated provider. This is labeled process compliance and aspiring providers will look to those good ideas, well designed procedures that save time, money, lives and improve the quality of care; these better practices will disseminate on the wings of competition to provide care to more people as more providers learn . As Porter and Teisberg point out
    “There is a fine line between difffusing best practices and standardizing medicine. The current rates of medical errors and inappropriate standards of care are unacceptable, so diffusion of guidelines to enocurage appropriate practice is essential . . .[This] is just a tool to enhance the true goal-improving risk-adjusted results.” p. 124. It seems to me that the scenario you outline in the example of the Mayo clinic is something straight out of Porter and Teisberg’s line of reasoning.
    Just a passing thought in summary-there are three major players in the health care arena-providers, consumers and health care plans(including the publicly supported ones like Medicare). They all commit grievous sins; and I’ll just name one for each-there are many that each player commits.
    1.Providers live in a world of cottages and spinning wheels, forcing patients to go door to door to gather care.
    2. Patients-consumers- refuse to educate themselves on health care options as completely as they are able-easier to let someone else do all the work while American Idol is on and the beer is still flowing from the tap.
    3. Health care plans are lost somewhere over the rainbow in a maze of Byzantine claim forms and zero sum competition-the question for them, which they never really ask, is competition about what? Better customer service? Hah!
    Well it’s been fun and keep looking up!

  79. Maggie,
    I’m familiar with your credentials, and I respect them. I also bought and read your book, Money Driven Medicine. I still disagree with you with regard to the for profit insurers.
    I’m a Wall Street analyst myself, albeit for a large corporate pension fund with an extremely long term investment time horizon. We have stocks in our portfolio that we have literally owned for decades. Part of my current responsibility includes covering the managed care companies and the PBM’s. My take is that investors want these companies to reinvest their free cash flow wisely to grow the business. We want them to make sensible acquisitions at reasonable prices to which they can add value once they own them. We like them to buy back their own stock when they think it is undervalued. We like them to invest in technology to make themselves more efficient and to more precisely forecast their medical cost trend. We want them to raise rates enough to cover their increase in medical cost trend and maintain a fair profit margin. We do NOT encourage them to drive profits by denying coverage to insureds. Besides, if they tried to do that, the non-profit insurers, including all of the Blues except for the 14 plans owned by Wellpoint, along with Kaiser, Harvard-Pilgrim, Tufts, Medica, etc. would eat their lunch. The non-profit insurers, by the way, still control between 30% and 40% of the private health insurance marketplace.
    On the subject of pleasing customers, the primary customers are the employers as you well know, and most of the larger employers self insure. They just engage insurers to provide claims processing, network access, and, perhaps, disease management. Most people I know who work for large employers (including federal, state and local public sector employees) are generally pleased with their coverage, though they are concerned about rising costs and the pressure it puts on wage growth. The individual insurance market, by contrast, borders on the dysfunctional. In community rating states, young, healthy people will pay over $4,000 per year for single coverage, and many choose not to buy the coverage even if they can afford it because they think it’s a poor value. In underwritten states, insurers do indeed try to avoid covering sick people, but healthy people can buy coverage quite cheaply.
    I still think the employer based system could be built upon by providing default coverage for those who lose their jobs, work for themselves or in tiny businesses that can’t afford coverage, people who retiree before becoming eligible for Medicare and anyone else who falls between the cracks. Premiums could be scaled to income while employers above a threshold size could be required to provide health insurance or pay into a fund to help finance taxpayer subsidized coverage. I could live with taxpayer funded vouchers or even Senator Wyden’s approach, though I think large employers provide good natural pools with enough healthy people to make the system work. Medicare for All is NOT the answer, in my opinion.

  80. rhetorical question: how long would the Mayo Clinic or Cleveland Clinic survive if those institutions only had revenue from a ‘medicare-for-all’ system?
    One more rhetorical question: when you look at total revenues, where do the dollars at those institutions come from? and, more specifically, break down the average revenue per patient, based on how they are paying (i.e. private insurance, medicaid, medicare, cash paying domestic and foreign)…

  81. Barry and Bev M.D.
    First, Barry, I realize I may seem overly cynical about for-profit insurers, but I spent 15 year of my career following Wall Street (12 of those as senior writer/senior editor at Barron’s) and I can attest to the fact that the vast majority of Wall Street analysts care only about short-term earnings–and that CEOs share that vision.
    As one analyst once said to me “Healthcare is a lot like the tobacco industry; the customer doesn’t have much choice.” If you’re sick, and your doctor or hospital tells you you need something, you will do your best to buy it. You won’t say, “I’ll wait until the price comes down.”
    There are exceptions among both analysts and insurance company executives. There are very intelligent, thoughtful people who realize that the health care industry is not selling roller-skates. I quote them in my book. But, unfortunately, they are in the minority.
    As for the idea that insurers have to please customers– how many customers do you know who are pleased with their health insurance company? How many feel comfortable with the fact that, according to Bloomberg:
    “The six-member Standard & Poor’s 500 Managed Health Care Index rose 22 percent in the 12 months through June of this year. “UnitedHealth increased 17 percent; WellPoint, 15 percent; and Aetna, 29 percent.”
    There is no reason why insurers should make much higher profits than most companies in the S&P 500. And other companies (who are paying these insurers to cover their employees) simply can’t afford the premiums that lead to these over-the-top double-digit profits.
    Fifteen or 20 years ago, Wall Street decided that healthcare should be a “high-growth” industry–i.e. one of the most profitable industries in the U.S. And since then, drug-makers, device makers, for-profit hospitals adn insurers have been trying to live up to those expectations– and largely succeeding. The result can be best described as “profiteering” on the sick- and the frightened– exorbitant prices for drugs, devices and insurance.
    At the same time, I totally agree that Medicare needs to do much more in terms of using evidence-based medicine to decide what to cover. The problem is Congress–and the lobbyists who own so many Congresspeople. But I’m hopeful that, as more Americans learn about the incredible power of these lobbyists over Congress, citizens will exert their own pressure on their representatives.
    Bev M.D. .– I completely agree with you that the best models for most patients are multi-specailty clinics like Mayo or the Cleveland Clinic. AS you say, it “marries the doctors and the clinic.” In other words, it is about collaboration, not competition. And that is what I think our healthcare system needs– more collaboration, less competitoin.
    Thank you all for your thoughtful comments – Maggie

  82. Specialists in other countries.
    Surgeons practicing within the NHS in certain specialties can earn in excess of $1-1.5m on top of their NHS salary which could its self be well in excess of $200k.
    Clearly their are specialties where this is simply not an option and I know of a number of professionaly who choose not to have a private practice as a matter of principle.
    Primary Care physicians are now compensated extremely well but thats what happens when you send civil servants to negotiate with clincians, who ever thought that was a bright idea should be summarily shot. There was only ever going to be one loser and that would be the government and they were.
    Outside of London the ability to earn enormous sums in private practice is limited but it does exist. I know of OBGYN surgeons making over $750k in private practice in one of the poorest parts of the country and his waiting list is growing.
    I am not sure that I have met any physicians or surgeons angry that they earning power is being limited by political mandates. They have the choice to enter practice and if they choose a specialty where private practice is limited or non existent they can hardly blame the government for that.
    I know that earnings relative to the US are lower but clinicians in the UK by and large make good livings.
    If they wanted to make superb livings and that was the driver they should have gone in to finance.

  83. Wow there’s a lot of worship at the Mayo alter on this forum. Before you try to apply the Mayo model to the rest of hte nation, perhaps you’d better look at the average income in the Rochester MN area and compare it to the national average.
    Furthermore, their ED runs at 70% less capacity than other similar sized urban areas because virtually everybody there has health insurance and they dont go to the ED for primary care issues.
    Mayo is a great clinic, but their results arent exactly generalizable to the entire population when you consider the standard of living and income levels in Rochester are a full 1.5 standard deviations above the national mean.

  84. Ms. Mahar;
    Thanks for your interesting comment. I agree with you that a for-profit company today cannot think beyond the next quarter’s profits. But I do think the concept of “health insurance” is somewhat of an oxymoron, in that the business of insurance is to avoid risk, and everyone, bar none, will eventually get sick and die.
    Therefore whatever you call the companies that eventually take over their function, they need to change their focus. They also fail to realize that improving quality DOES save money and therefore increase profit – again, as you point out, due to short-sightedness. However, I don’t think that changes the basic merit of Porter et al’s idea of competition based on value, even though yes, some of their implementation ideas are unrealistic.
    I have thought about this a long time and have concluded that a Mayo or Cleveland Clinic type structure may be the highest quality and most efficient form of medical practice and health care delivery. It marries the doctors and the hospital, aligns the financial incentives, leads to greater internal coordination, and produces an organization with extensive experience in coordinating
    with outside referring institutions – as demonstrated to my admiration bya friend of mine’s recent experience with cardiac valve surgery at the Cleveland Clinic. (Porter et all also make reference to the Cleveland and Mayo clinics in their concept.) To my surprise, I also discovered the Clinic also has an ER, so one cannot argue they would only take the cream of the crop.
    Perhaps there should be such “centers of excellence” strategically spaced geographically throughout the country, coordinated with affiliated community hospitals. One would have to compete to become a center of excellence in one’s geographic area.
    As to the form of payment for all this, I leave that to you business-type people. All I know is that, if you try to universally insure everyone in the system as it presently functions, you really will go broke no matter how you do it.

  85. Maggie,
    Two comments.
    First, I think you are being too hard on the private insurance sector, especially the for profits. Both for profits and non-profits are far ahead of Medicare in trying to develop premium networks, encouraging their members to use them, and making modifications in benefit design to improve the members’ incentives to choose one of the more cost-effective providers. Price and quality transparency, a user friendly website, health coaches, disease management, etc. are all part of the offering which more and more employers are choosing to pay for. I get a little impatient with the constant harping about meeting Wall Street’s quarterly earnings expectations, maximizing profits and CEO’s earning outsize bonuses and stock options. Like any other business, they have to please customers. If they don’t please enough customers enough of the time, they eventually won’t have any customers left to please, and they won’t have a business. According to the CBO, over 150 million Americans get their health insurance through their employer, and over 80% of those are part of groups of 50 or more. I, for one, have worked for four different companies over the last 36 years and had plenty of medical claims in the last 15 or so, yet have never had a problem with coverage or payment. While the individual insurance market has plenty of problems because of the adverse selection problem, employer based coverage is pretty darn good from what I can see.
    Medicare remains well behind the curve in identifying the most cost-effective providers and encouraging beneficiaries to use them. If funding and/or legislative authority are issues, that’s Congress’ fault, and it does not inspire confidence that turning the whole system over to a government financed Medicare for All approach would improve matters. Even if it achieved universal coverage (certainly a good thing), it would not contain cost growth.
    Second, with respect to centers of excellence, heart disease is a chronic condition. If a patient with heart disease needs a CABG or a DES, he or she is almost certainly better off receiving those procedures at a regional center of excellence. Since I’ve had both of these, I know something about this. At the same time, my NYC cardiologist, who is part of a multi-specialty group practice, does an excellent job in monitoring and managing my (and his other patients’) condition. He knows what medications I take, does periodic blood tests, and can do the appropriate stress tests, including a stress echo when required, in his office. Centers of excellence are also probably appropriate for cancer treatment, organ transplants, and other very sophisticated surgeries.

  86. Thank you for your comments.
    Let me respond to a few of them:
    First, Terry, thanks for giving us an insider’s look at the U.K. system–it’s especially helpful becomes it comes from a professoinal working within the system. What you say confirms what I have found in my research: health care systems in other developed countries all have their flaws–and patients have complaints– but the majority of doctors and patients seems to agree that they would not trade their system for ours.
    There is one exception: specialists in other countries who know that they could be making much more money in the U.S. are sometimes deeply resentful of the fact that they goverment is making an effort to contain costs. They’re making, say, $200,000 a year and they feel they should be making $500,000. . .
    The other thing I’ve noticed is that U.S. doctors are far more critcal of our system than the average U.S. citizen. (See Bev M.D. and Scott Robertson above) This is, no doubt, becuause the average citizen is not sick most of the time, while the average doctor sees what is happening to U.S. healthcare day in, day out.
    On foreign doctors: Joe Blow is right, we are already importing a large number of doctors, and when we take them from developing countries, we are taking physicians who are badly needed at home . . . Moreover,
    we have enough doctors in virtually all specialties except family medicine, General Practice, and pediatrics. Because these areas are not as well paid as other specialties (another problem in our system–and a reason why we have less preventive care) fewer med students choose family medicine, etc.
    On Michael Porter’s book: Porter and Olmstead are right to recognize that our competitive system healthcare has turned into a Hobbesian marketplace where a war of “all against all” pits hospital against hospital, doctor against hospital, hospital against insurer, etc. As they write: “competitors do not create value, they divide it. And sometimes they destroy it.”
    But their solutions ignore the real world of health care. For example, they suggest that chronically ill patients should be sent to “centers of excellence” –hospitals that specialize in a particular chronic disease. The problem with this idea is that, by definition, chronically ill patients need consistent, long-term care–which means that they need care near their homes. Most can’t go to a center of excellence in another state and live there for the rest of their lives.
    Secondly, patients do not present neatly, one chronic disease at a time. Many chronically ill patients suffer from two or three chronic diseases; they need to be treated in multi-specialty centers where doctors specializing in their various diseases can collaborate with each other.
    Centers of excellence can work well for certain things, but not most chronic disease. Yet, as Porter points out, chronic disease is the biggest area of health care spending, so we need to focus on quality and efficiency in this area.
    Porter and Olmstead also suggest that doctors should compete on quality, and that the best doctors could then be “rewarded” with the most patients–and thus there is no need to worry about “lifting all boats–i.e., trying to improve the quality of healthcare among doctors in the middle of the curve. The problem with that idea is that doctors with a reputation for being “the best” already have more patients than they can handle. They have only so many hours in their day. The way to improve quality is not to try to send all patients to the top 20% of doctors, but to have doctors working in multi-specialty group practices (like the Mayo Clinic ) where they are working together, all looking at the same chart, and can collobrate, with the most experienced and most talented doctors helping others.
    Tom Leith– you are right that in the 1980s managed care was more often about managing care (not costs) and Americans did not like being told “no”–even if “no” was the right answer (based on medical evidence). I’d add that in the 1980s, many more HMOs were still not-for-profit. (Before 1980, almost all were not-for-profit, then Reagan changed the law that gave not-for-profits tax breaks, and by 1990, more HMO’s were for-profit).
    For-profits are more likely to manage costs–and less likely to manage care–becuaue they have shareholders. And under American law, a for-profit corporation’s first obligation is to make money for those shareholders.
    Bev D.– This is why I think that the idea that for-profit insurance companies will become patient advocate companies looking for the highest quality care for their customers is unrealistic. That’s just not how most CEO’s in the corporate world think. There are exceptions, of course, but by and large CEO’s think in terms of pleasing Wall Street, and because WAll Street is not patient, this leads to short-term thinking.
    Aiming for high quality and efficiency would require long-term thinking. For exaple, a truly enlightened insurer would think about helping hospitals and doctors pay for electronic medical records, knowing that,despite high upfront costs over the long term,these records would reduce errors and help avoid waste. But so far as know, the only insurers who are helping to pay for EMRs are not-for-profits.
    By contrast, within the world of for-profit insurance, most CEOs are focued on making sure that quarterly earnings meet Wall Street’s expectations– so that their share prices will rise and they will be rewarded with more bonsues and a richer options package.
    Finally, I agree with those of you who say that Moore’s movie was made for Joe Sixpack–and rightly so. We need to engage the American public in a national conversation about healthcare. And those of you who point out that value and effiency are the greatest problems are right, too. The good news is that we have plenty of money sloshing around in the system to provide good care for everyone. After all, other countries provide very good care in many areas while spending roughly half of what we do. So it’s not a question of not being able to afford univereseal care– it’s a question of avoiding the wasteful care that is driven, all too often, by a quest for profits.

  87. Excellent movie from Michael Moore..Its clearly highlighted the problems and holes in the Medical policy in the US.Hope government will not look it as a criticism, rather take it as a guide to give better policy to peoples…
    mobile phone deals

  88. Michael Moore always goes over the top. It is best to regard him as a latter day Hogarth; he exaggerates for effect. The greatest charge against American Medicine is that it does not get value for money – but that is America; value for money is not a priority. If it were no-one would be driving SUVs.
    Let no one think that a single-payer system is the perfect answer. The British NHS has plenty of flaws – I have practised in it for 40 years. Some of the problems derive from too much government interference, some from too much influence from pharmaceutical companies and some are a consequence of the greed of doctors. Monpolies have their drawbacks and all professions are conspiracies against the laity. Nevertheless, For all its flaws it gets much better value for money than the American system, and for all but a very few, a standard of care that is as good as or better than that in America. There are just as many nurses per head of population, but only half as many doctors. When I see doctors’ letters from America I am amazed at the extraneous detail that they contain. Whether this is about covering their backs or to justify their fee I can’t ascertain.

  89. “Maybe there needs be more price and quality variation? Lower the med-school standards, invite doctors from other nations and let them practice here.
    I can go to Costa Rica and get a week’s vacation as well as all my teeth capped for half the cost here. Why not bring that doctor here and save the carbon footprint of my medical tourism? Sure, he might not earn enough to drive a Bently, but he can roll around in a perfectly good Audi just like the UK doctor.”
    USA takes in more foreign doctors than all other nations COMBINED. The USA is the easiest nation of any in the industrialized world for immigrant doctors to enter. Over 40% of all doctors in the USA are foreign born.
    USA is in the top 20% of industrialized nations in terms of doctors per capita.
    Conclusion: the USA has plenty of doctors, and we keep stealing docs from 3rd world countries whose healthcare systems are FAR WORSE than ours; in fact most of them have no healthcare system at ALL. We are poaching their best and brightest and as a result their healthcare delivery system is non-existant.

  90. “Maybe there needs be more price and quality variation? Lower the med-school standards, invite doctors from other nations and let them practice here.
    I can go to Costa Rica and get a week’s vacation as well as all my teeth capped for half the cost here. Why not bring that doctor here and save the carbon footprint of my medical tourism? Sure, he might not earn enough to drive a Bently, but he can roll around in a perfectly good Audi just like the UK doctor.”
    USA takes in more foreign doctors than all other nations COMBINED. The USA is the easiest nation of any in the industrialized world for immigrant doctors to enter. Over 40% of all doctors in the USA are foreign born.
    USA is in the top 20% of industrialized nations in terms of doctors per capita.
    Conclusion: the USA has plenty of doctors, and we keep stealing docs from 3rd world countries whose healthcare systems are FAR WORSE than ours; in fact most of them have no healthcare system at ALL. We are poaching their best and brightest and as a result their healthcare delivery system is non-existant.

  91. “This film was NOT made for doctors, nurses, hospital administrators, and especially NOT for those of us that read healthcare blogs. It was made for Joe Sixpack who is completely clueless about how this business works both here and abroad. Trust me – Mr. Sixpack needs to be educated, even if it comes from Michael Moore.”
    A great post Scott. But Mr. Sixpack also needs to be educated in the political system that prolongs the lack of a healthcare solution. Mr. Sixpack needs to be educated in the “follow-the-money” politics that prevent solutions for all but the monied. That was also the theme in Moore’s “Fahrenheit 911”. But I think Mr. Sixpack already knows this and this is why he has tuned out of politics and voting.

  92. “Canadians, by law, cannot buy insurance for anything covered by the public system”
    Why would they want to, they’re already covered?

  93. I agree with Mr. Vernier; most of these comments seem to be the same tired my-payment-system-vs.-your-payment-system argument frequently seen on this blog. (Complete with exchange of veiled insults whenever certain unnamed commenters are involved.) I couldn’t care less about Mr. Moore or his movie except to the extent that he stimulates discussion, as others point out.
    Mr. Vernier, however, has hit the nail on the head that we need to be concerned most with quality and efficiency of delivery, both sorely lacking now. Also, I find a concept in Porter’s book interesting – the proposed transformation of “insurance” companies into patient advocate companies who seek out the best VALUE care (defined as highest quality per dollar spent) for their patients. (This is in contradistinction to “managed care” which truly was, as Ms. Mahar says, “managed costs.”)
    These companies, not poor Joe Blow patient, have the infrastructure to discover this information and use it to both save themselves money and get the best care for their covered patients. If only they would show some leadership and actually do it instead of avoiding sick people and whining all the while.

  94. Thanks for giving this issue the attention it deserves. As health care costs continue to soar, I expect more and more employers will bail out of providing health care insurance the way they have pensions. The number without insurance will increase. Visits to emergency departments for non-emergency care will go up and ED’s are in trouble as it is. I don’t think insurance mandates or HSA’s help those that can’t afford or qualify for insurance. I’m afraid a single-payer system, as most other developed countries have, makes the most sense to me, by potentially reducing cost and complexity, coupled with some nominal co-pay to cut down on “frivolous” visits. However, I really don’t know if we can afford that or if we can afford not to do it, and of course I am leary of government ineptitude.
    Do you not find it ironic that in your first sentence you call for the death of Michael Moore for making “Sicko” and in your closing paragraph you bemoan the loss of
    the ideal of being able to speak one’s mind without fear of reprisal? Just asking.

  95. I am astounded that in all of the discussion over health care, no one seems to have read
    “To Err is Human: Building A Safer Health System”
    available here-
    The major cost factors in health care are those surrounding the topic of quality.
    Too much care, too little, too much of the wrong kind, uneven practices; the list is horrendously long.
    My second recommendation for those who are seriously interested in ways to raise the quality of care in this country,is to read
    “Redefining Health Care, Creating Value-Based Competition on Results” by Michael E. Porter and Elizabeth Olmsted Teisberg.
    When we stop paying the low quality providers for giving terrible service we will have made a tremendous step in reducing costs.
    When all consumers are able to obtain informed opinion and assistance in selecting only quality providers, we will have made another tremendous step in reducing costs.
    Michael Moore’s film seems to be more about rabble rousing than raising facts.

  96. Peter, you’re quite amusing.
    Canadians, by law, cannot buy insurance for anything covered by the public system – essentially all the things that would kill you.
    I find you just barely worth responding to.

  97. Mr. Holt,
    It’s been a while since I have posted – but I have been lurking and enjoying the blog.
    I have seen SiCKO twice – and even though it is full of Mr. Moore’s half-truths and one-sided arguments – I think it is a great film. Yes, I am a physician and a Republican, but the healthcare crisis in the U.S. needs this attention. If we are lucky, our elected officials might see that healthcare DOES matter to patients (and voters).
    This film was NOT made for doctors, nurses, hospital administrators, and especially NOT for those of us that read healthcare blogs. It was made for Joe Sixpack who is completely clueless about how this business works both here and abroad. Trust me – Mr. Sixpack needs to be educated, even if it comes from Michael Moore.
    Mr. Moore asks “Who are we? Is this what we’ve become?” and as a society, that is a question that needs to be answered and addressed. Hopefully, this film will rekindle dialogue in healthcare policy that has been sorely absent for the past 15 years.

  98. Maybe there needs be more price and quality variation? Lower the med-school standards, invite doctors from other nations and let them practice here.
    I can go to Costa Rica and get a week’s vacation as well as all my teeth capped for half the cost here. Why not bring that doctor here and save the carbon footprint of my medical tourism? Sure, he might not earn enough to drive a Bently, but he can roll around in a perfectly good Audi just like the UK doctor.

  99. Posted by: Stuart Browning
    “Interesting. The topic here is Sicko. In that movie, Moore advocates abolishing private insurance. There are only three countries that have: Canada, North Korea and Cuba.”
    Really Stuart? How about this:
    “Private Health Insurance” (In Canada)
    “While the health care system in Canada covers basic services, including primary care physicians and hospitals, there are many services that are not covered. These include things like dental services, optometrists, and prescription medications.”
    “Private health insurance plans are usually offered as part of employee benefit packages in many companies. Incentives usually include vision and dental care. Alternatively, Canadians can purchase insurance packages from private insurance providers.”
    “The main reason many choose to purchase private insurance is to supplement primary health coverage. For those requiring services that may not be covered under provincial health insurance such as corrective lenses, medications, or home care, a private insurance plan offsets such medical expenses.”
    “While private insurance can benefit those with certain needs, many Canadians choose to rely exclusively on the public health system.”
    The reason private health insurance in Canada is not necessary is because the single pay government run health insurance system covers most everything.
    Stuart Browning’s usual Limbaugh rant.

  100. Haven’t seen the movie yet but saw an interview with Moore about it.
    Moore says that he advocates “taking the best” from other countries to re-make the US system. Everything in Canada, England, France, etc. isn’t perfect…but a lot is good. And what we have is clearly not working.
    Believe it or not, rationing is alive and well in the US health system. A couple of years ago, that noted left-wing publication, the WSJ, had a series on it. Here’s a link:

  101. Interesting. The topic here is Sicko. In that movie, Moore advocates abolishing private insurance. There are only three countries that have: Canada, North Korea and Cuba.
    There seems to be a general agreement here on this blog with the stances taken in Sicko. So, if Canada is not the model, then I have to assume that you like one of the other two systems.

  102. Very nice review Maggie. I saw the film yesterday. When it wasn’t tragic it was very funny.
    > In the 1990s, when insurers said they were trying
    > to “manage care,” many were simply “managing costs.”
    To be fair, in the 1980s when managed care was often about managing care, uber-individualistic Americans hated the limitations on the choice to buy flat-of-the-curve medicine implied by management and (egged-on by the whole medical establishment) got managed care effectively outlawed. And everyone got what they deserved in the 1990s.
    > look at my film “Two Women”
    OK, I have. It wasn’t funny at all, and I’m glad its only 4:32 long.
    This circumstance is a good thing to avoid, thank you so much for pointing it out. Owattans (not Canadians generally) seem to have made their Rawlsian choice. I am sure we will make a different one.
    > Rationing by physical force – … – is the issue.
    Says who? You? chortle! For most people there is no difference among “rationing by price” and “rationing by obfuscation” and “rationing by physical force”. Perhaps you’d be happier if the dear woman had lost her bladder because of an inability to pay. Upon reflection, I don’t think there’s any “perhaps” about it.
    Fortunately, Canada is not the only possible model. If it were, we should have to invent a new one.

  103. matt – you must be drinking Mr. Holt’s kool-aid. The only rationing of health care in the U.S. is done in government programs and hospitals – just like Canada & the U.K.
    The whole “rationing by price” garbage is a non-starter. Rationing by physical force – as single-payer regimes do – is the issue. If you want to see real government rationing – then a look at my film “Two Women” (http://freemarketcure.com/twowomen.php).

  104. “As I suggest below (see my most recent post on MedPac ) the public will always be suspicious of decisions made by for-profit insurers—even when their decisions are based on sound medical evidence. For-profit insurers just don’t have the political or moral standing to make these judgments. (By contrast, most patients are much more comfortable with Medicare’s coverage decisions—which is why we need a federal agency testing and comparing the effectiveness of new treatments. )”

    For another view of who people trust for health advice, recent JD Power poll results:
    Results of a JD Power poll asking consumers which entities they trust for health information
    This poll suggests people trust Medicare less than they trust health plans – and that they don’t trust either very much.

  105. Great review, Maggie! Agree that what Moore does best is to draw attention to the reform debate “loudly and clearly.” Another loud and clear commentator is economist Uwe Reinhardt, who has been interviewed about SICKO on NPR. Twenty years ago, Uwe wrote compellingly that the US, which tends to its uninsured via charity care, needs to look to the efforts of other countries and consider its “implicit social contract” re health care in a more explicit manner. Health Affairs Blog muses today on SICKO, the social contract, and communitarianism.

  106. Moore is a leftist captialist of the worst sort and should be given his just reward, a tree and a rope.
    Rolf! This is way more worthy of Castro, Sadaam or Bin Laden than it is of an ostensible defender of the American way!
    Whatever happened to freedom of expression, the marketplace of ideas, I-reject-what-you-say-but-would-defend-to-the-death-your-right-to-say-it… all of those things that people fled theocratic Europe for to come here and build a new way of life!!! A way of life where people could speak their mind without fear of violent reprisals because of the perceived treason of independent thought!

  107. Ms. Mahar would have her readers believe that only private insurers “spend a great deal of time designing policies that will limit their losses”. However, the governments of Canada and the UK achieve precisely the same outcome by limiting the supply of medical care available (specialists, technology, OR hours).
    When it comes to health care financing, either an individual makes his own medical decisions – or a gatekeeper representing a 3rd party does it for him. The latter results in a veterinary ethic of medicine in which the standard of medical care is not what’s in the interests of the patient – but what is in the interest of the payer – or owner.

  108. Medical insurance. Just another way to make people frightened. Just another way to go left. Just another way to take away the just rewards of the gainfully employed. Wait in long lines or establish Argentine’s medical system where the rich get treated and the sheep get nothing. Our system is the product of the Social Security system. A fine left wing institution that led the way to off balance market forces in a free enterprise system and replaced it with a “I pay for you as your personal slave system”. The answer is not for the government to have more of the people’s money but rather for the system to cater to the market forces of the system that it was intended to cover. If the system was limited to the means of the common individual prices would drop and care would be the same with the knowledge that our doctors would not have 10 cars and 2 homes. A point that is largely left out of Mr. Moore’s film. When market forces are artifically supported, they will eventually fall. One other point that should be noted, all of those nations that have universial health care sacrifice other areas that receive little or no attention. For example, Canadian could not fight off the invision of a blind army because it has woefully underfunded its national defense relying instead upon the good old United States for its national defense. Its medical care system would change very rapidly but for that fact. Perhaps those on the left should see the forrest through the trees. Moore is a leftist captialist of the worst sort and should be given his just reward, a tree and a rope.