Matthew Holt

Op-Ed: Why the Senate should be abolished, Parts 34-36

Irrelevant small states with no people in them that exist by an accident of history are chronically over-represented in this country — both in the electoral college and most obviously in the Senate. And those states are much more conservative than metro areas where people actually live, which means that even if they send Democrats to DC, they’re not exactly raging Trotskyites.

Hence we get Max Baucus, representing less than 1 million people, or one-sixth of an average state’s population, pushing moderate reform and saying that single-payer is a political non-starter. He’s right, but it’s only because of the political structure that guarantees him his power. If San Francisco, which has roughly the same population as Montana, sent a Senator to Congress I think the result would be somewhat different.

Meanwhile the same issue means that, as it stands, the stimulus bill which apparently is our only hope doesn’t have enough votes to pass, while a moderate Republican (yes, they found one) from Maine and a conservative Democrat from Nebraska (yes, they don’t just shoot them all there) are basically charging themselves with being “responsible” and scaling it back.

But don't worry, in health care the story remains the same. What are they trying to scale back?

Among the items that the Collins-Nelson initiative is targeting: $1.1 billion for comparative medical research <SNIP>. The medical research measure, aimed at developing uniform treatment protocols, is an Obama priority and part of the foundation he is trying to build for health-care reform

So the most sensible thing in the whole darn package gets cut. But just in case you were worried that we’re just going to cut comparative effectiveness research which any moron every health policy wonk will tell you is something we desperately need more of, here’s something to really make you despair:

And the chamber ended the night by unanimously accepting an additional $6.5 billion for research at the National Institutes of Health, pushing the cost of the Senate legislation — for now — to more than $900 billion.

We already spend nearly $30 billionish on research via NIH, and we spend a bucket of cold spit assessing what actually happens in the real world at AHRQ. And we wonder why we have so many ineffective widely used treatments.

Stalin would never have put up with this!

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22 replies »

  1. Nate,
    Doctors, nurses, pharmaceuticals are valuable commodities that provide services. Insurance companies are middle men who add NO VALUE to the system and instead siphon profits off the top.
    You cant have healthcare without doctors, nurses, and drugs. You could easily have a healthcare system without ridiculous private insurance middle men stealing 30% of the take.
    A socialized government run healthcare model will save billions of dollars over a private insurance scam.

  2. Deron, a book’s intro does not revel much, it’s an easy read and not complicated at all, believe me. All I can do is lead a horse to water.
    “It’s going to take a massive push for education.”
    Very difficult when all people (including children) see is “super size me”. The biggest education program out there is corporate food marketing.

  3. Peter,
    I know you hate insurance companies and blame them for everything and think government is the problem….
    Any willing provider laws, passed by politicians, is one of the main reasons doctors are in every network. Like most succeful cost containment programs the very politicians you look to for salvation destroyed them. As you listen to me run on and on you’ll start to notice, hopefully, that politicians create the majority of the problems we have. When those evil insurance companies and free markets find a solutions it’s usually only a couple years till politicians break it.

  4. I read the intro to Omnivore’s Dilemma. It seems like a very interesting, but possibly more complex the necessary, assessment of our problems. There’s no doubt that there are harmful foods being marketed and sold to us every day. Nonetheless, we still have self control issues as a society. Something as simple (or difficult) as controlling portion sizes would go a long way to improving our health status. How many reading this have had a snack when you weren’t even hungry? The cliche living to eat instead of eating to live really sums our problems up.
    What we’re putting in our body impacts every single aspect of our health. We should not lose sight of that, but most of us have. It’s going to take a massive push for education. I’ve said before, I think we need a graphic prime time TV series that depicts what we’re doing to ourselves. People need to see the connection between unhealthy habits and trouble down the road.
    If nearly every U.S. citizen lead a healthy lifestyle, most of the things we talk about here would be non-issues and, in fact, THCB would probably not exist. In my mind, it’s that serious. The billions that Obama wants to devote to HIT should be redirected to this transformational effort.

  5. Nate, interesting you used PPO as example of how insurance has controlling costs. Not many people are noticing it working. Here’s the other side:
    “The rise of PPOs was credited by some[who?] with a reduction in the rate of medical inflation in the U.S. in the 1990s. However, as most providers have become members of most of the major preferred provider organizations sponsored by major insurers and administrators, the competitive advantages outlined above have largely been reduced or almost entirely eliminated, and medical inflation in the U.S. is again advancing at 150–200% the rate of general inflation.”

  6. “Why do insurance companies and Medicare have the responsibility of “controlling costs” in the first place?”
    If everyone had to pay for their own insurance policy based on their health and lifestyle without any corporate or tax payor bail out they might actually stop smoking, take care fo themselves, and not waste money on questionable medicine.
    What the heck would politicians run on then? Without problems to solve we might actually wise up and question why we send trillions to washington every year.
    This also applies to education, what if parents kept all those billions in tax dollars and where responsible for their kids education?
    personal responsibility is the single greatest threat to our government as it stands today. Someone take Deron out back and shoot him before someone hears him!

  7. “If San Francisco, which has roughly the same population as Montana, sent a Senator to Congress”
    Doesn’t San Francisco already send two Senators (Boxer and Feinstein)? Not to mention the Speaker of the House.

  8. Matthew – I normally love your stuff, and perhaps I am missing some sarcasm here, so forgive me – but:
    As a transplant from a supposedly “relevant” state to one that is clearly “irrelevant” I can only say thank God I don’t have to do what people in SF think I should.
    Our founding fathers were brilliant – don’t try to paint poor decision making by politicians as some kind of regional us (“enlightened elite”) versus them (“morons in the middle”). That would be very pelosic of you.

  9. “Seems to me that individuals should be taking more responsibility for that.”
    Everyone should be taking responsibility. Including food corporations who promote junk food to children, industry that pollutes our environment, food producers that continue to manufacture and sell product even though it contains salmonella, for which the FDA has been handcuffed by industry lobbyists so that it cannot be proactive and order a recall, toy manufacturers who use lead, etc, ect, ect. Deron, read, “The Omnivore’s Dilemma” by Michael Pollan if you want a real understanding of our bad food habits.

  10. Why do insurance companies and Medicare have the responsibility of “controlling costs” in the first place? Seems to me that individuals should be taking more responsibility for that. It’s a shame no one wants to talk about that. I guess it’s not politically correct.

  11. Nate, can you name any insurance program that has been effective in controlling cost
    Claim Audits
    unbundling audits
    medical record reviews
    leveled co-pays
    generic substitution
    disease management
    educational inserts
    nurse help lines

  12. MD as Hell, sorry for the misread. I also get enraged when I hear about heroic attempt$ to get just one more month of life from an 80 year old, but can you imagine the outcry if docs have complete control of end of life. How do other countries handle single-pay without having “The fear factor” overwhelm the system? Is their culture that different? Barry Carol believes we should all be compelled to make a living will – not a bad idea and maybe a stipulation of coverage. In Taiwan system they have smart cards tracking patient healthcare use. When they see too much patient use patient is brought in for “interview”.
    I don’t own a cell phone, don’t need one, don’t want one, so there’s not much panic in my life. Other than business, what do all those people talk about?

  13. Nate, can you name any insurance program that has been effective in controlling cost – oh wait, yes; coverage denial, retroactive coverage cancellation, quoted pre-condition premiums Howard Hughes would have trouble paying, high deductibles people can’t pay. A profitable insurance industry equals a healthy population, or is it just a cherry picked population.

  14. “This is the first step towards having CMS act like a responsible purchaser of health care.”
    Really docanon? I would have thought the first step would be a little easier, like making sure your not buying care for dead patients or care approved by a dead doctor. Maybe before they go running around the block they could learn to walk by making sure the care they pay for is delivered or the person being paid even has an office.
    “There’s no reason to inherently trust or distrust the government.” Said the person hoping we trust the government with more of our healthcare. I have linked pages worth of examples of the failures of Medicare, Meidcaid,and SCHIP, more then enough examples to justify an inherent distrust of their ability to cost effectivly manage anything. It’s plain gulable to trust the government to run a healthcare system unless your comfortable with double digit waste and fraud.
    That being proven why do we want to waste money for CMS to study comparative medical research? How has CMS disease management worked out…oh they just cancelled most of it? How has all those billions invested in fraud prevention panned out….crooks just found another Medicare scam to work.
    Can you name ANY CMS programs that have been effective in controlling cost?

  15. I’m glad to see residency affords a little blogging time.
    There’s no reason to inherently trust or distrust the government. It is ignorant to assume that all people within government are untrustworthy and incompetent (or the opposite). Simplistic jingoism helps nobody…unless of course you have a political goal that includes winning the votes of those who can’t absorb a rational argument.
    That said, effectiveness + affordability = appropriateness.
    This is the first step towards having CMS act like a responsible purchaser of health care. Given the chronic underfunding of health services research, comparative effectiveness projects are about as “shovel-ready” as anything you’re likely to find. Yes, it is stimulus. Ideal stimulus, actually…ask any economist about something called “the multiplier” as it pertains to research.
    Better yet, when the recession is past, we get to reap the fiscal benefits in terms of slowed spending on wasteful and harmful medical procedures. On the margin, effectiveness research should be able to overpower those who advocate high payment for truly useless stuff (e.g. coronary CT vs. treadmill + ECG, elective coronary stent vs. supervised exercise training, proton beam vs. standard XRT, etc). If there’s no added effectiveness to a new technology in head-to-head analyses, why on earth should we pay more for it?

  16. Peter, you artfully missed my point. My short list of items are also covered now, usually by a single payor (MediCare) and we have runaway consumption of these services because the patient and the family have no incentive (or disincentive) to make pragmatic real-life choices. Doctors should make end of life medical decisions, not families. Families can rarely handle any guilt they might feel choosing to terminate futile care. As far as the uninsured getting gouged, I agree with you. But that condition was also established by the big payor wanting an extorted and coerced deep discount. Nevertheless, they (the uninsured) do make healthcare purchases when they need/want them, and are not terrorized into accepting studies based on the risk-averse risk management parameters used by doctors and insurers. It is a factor in healthcare.
    Cover everyone and everyone will live in terror that they might miss an experience, without which they may die instantly. The fear factor will overwhelm teh system. Have you noticed you now feel uneasy when you forget your cell phone at home, when you used to feel fine before they ever invented the cell phone?

  17. “1. Who will NOT get dialysis.
    2. Who will NOT get a feeding tube.
    3. Who will NOT get Home Health.
    4. Who will NOT get a hip replacement.
    5. Who will NOT get sent to the ER from the nursing home.
    6. Who will NOT get CPR.”
    MD as Hell, if you want to know who in Canada (and other single-pay countries) will not get the above, NONE, because they’re all covered and paid for. If 2, 5, and 6, are end of life, the patient and their family make the decision, at least in Canada. As for #4, that wait time (not no time) problem was corrected with additional funding as were cataracts. Here the patients more likely not to get the above are the uninsured poor or those on Medicaid.
    As for your so called “free market” for the uninsured, that’s a hoax as they get shafted at paying 3-4 times what hospitals would accept from insurance. Free market assumes you have a choice as to what to buy and if to buy – not a factor in healthcare. The fact they may have assets only means that gives hospitals license to gouge the hell out of them just for the hell of it.

  18. docanon: The items I listed need no study for effectiveness, but for appropiateness. There is no free market in healthcare, except with the uninsured who have assets. The RBRVS is decades old and from an era where people participated in the cost of care. Its present application is politically slanted.
    Do you trust anyone in government to solve anything but a political problem? It is not coverage that needs to be decided. Of course effectiveness should be studied, but that’s not where the big costs are and where the potential savings are. This should not be in the “stimulus bill”.
    I am a 27 year ED doc. I don’t think I am ignorant. I know I am not gullable.

  19. What breathtaking ignorance.
    MD as HELL: How, exactly, do you think coverage decisions for medical services should be made? How should the payment amounts be set? Are you happy with the current RBRVS payment system, which handsomely spends your tax dollars on harmful treatments…or do you think that maybe effectiveness matters? All these allocation questions you raise: how do you plan to responsibly answer them without the necessary data on effectiveness?
    Do you cling to the idea that a free market will solve all of this?
    If so, I’ve got a fantastic hedge fund for you to invest in.

  20. Wait don’t tell me — they want to increase NIH funding for Complementary and Alternative Therapies?

  21. Thank God the Founding Fathers wanted to keep us from every flimflam and scam being passed into law. The Senate and the Electoral College are what keep both Montana and New York from being merely counties in a large single state.
    Irrelevant small minds will sell their souls for control over other people’s healthcare. All your precious policy becomes irrelevant in the exam room, where I see patients who have illness, or are worried that they do. Not a single study will tell me how to treat a patient, only an illness.
    Is it really true that “reform” only needs a single person to pull it off? Have him call me and tell me:
    1. Who will NOT get dialysis.
    2. Who will NOT get a feeding tube.
    3. Who will NOT get Home Health.
    4. Who will NOT get a hip replacement.
    5. Who will NOT get sent to the ER from the nursing home.
    6. Who will NOT get CPR.
    These items require political courage, not testing. Don’t tell me how to cut costs or what YOU think is more effective until you (Congress) do what only you can do. That would include the Senate.

  22. Thank you Matt!
    While I’m not so sure about the “irrelevancy” of low-population states, there’s no doubt that they have power disproportionate to their populations…both in the Senate and in the Electoral College.
    Thank you for calling attention to this attempt to target comparative effectiveness research for destruction. It’s mind-boggling to think that this spending item–which is the only item with a prayer of slowing medical cost growth–should be on the chopping block. Even without a stimulus bill, this kind of research needs to be funded.
    Who exactly is lobbying these senators? Who are the campaign contributors who will benefit from continued wasteful spending on harmful and ineffective medical technologies?
    I smell a rat.

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