Matthew Holt

Reform? Marginal, I fear…

Matthew HoltToday’s news is that there is now a double header running health care with the addition of the 
(notably all-female) team of Sebelius & DeParle joining Orzsag, Zeke Emmanuel and a host of others with influence on the health care policy tiller. We await a CMS leader, and probably multiple other appointments quickly down through the ranks.

However, I remain convinced that not much is going to happen, and that even if Obama’s “plan” gets enacted, it’s a limited reform that is not the big bang we need to do the job.

Thankfully rather than me having to explain why, Bob Laszewski (who makes me feel like an inadequate noobie every time I read his stuff) details the problems over at Health Affairs blog. The Bob L summary?

  1. Obama’s team has not aggressively gone after the hard cost problems as part of Medicare & Medicaid, preferring to trifle around the edges with modest cuts 
  2. For the (these days relatively modest!) $120 billion a year the reforms are going to cost it’s only looking to the health care system to pony up around half of it—the rest (c. $65bn a year) will come from the taxpayer.
  3. The details of the plan are being left to the Congress which means that it’ll be watered down.

As I said in the looooong comment thread on Maggie Mahar’s piece on THCB yesterday—BTW Maggie’s comment on her own piece may be the longest comment I have ever seen on any blog!—there’s no reason that the rest of the economy should contribute more to the health care system. As John McCain might say (albeit with disapproval), we need to redistribute the wealth within the system.

Furthermore, despite Orzsag’s understanding of the long-term impact of health care cost increases, there doesn’t seem to be any indication of how the overall cost increases within the system is going to be ratcheted down. Zeke Emmanuel (echoing Vic Fuchs) has an answer in his excellent book—tie health care costs directly to a visible VAT tax that can only be increased by a Congressional vote. But the Obama team thus far says, we understand the problem, but we want to punt the reform process to Congress. They’re not even apparently insisting on a public plan as part of their package, or at least it’s not in the eight principles.

Now I understand that they don’t want to repeat the Clinton mistakes of taking too long and over-detailing the approach. And I would be OK if they took the LBJ approach and basically bought off all the interest groups and spent that extra money, if we achieved the real issue behind health reform—getting everyone covered in a single social insurance pool. Because if we did that first thing, we could fix everything else later.

But instead we’re going to get some mealy-mouthed version of pay or play which, if it survives the small business lobby (and I doubt it will) will only get us about half way to solving the uninsured issue, and will leave in place the terrible mish-mash of employer-based insurance, private insurers with mixed incentives, competing incoherent benefit packages, and Medicaid as a default and screwed up stop-gap.

And the result of that will be a still large group of uninsured and no real single source for cost-containment. Which (as I’ve said a gazillion times before) means that the system will still be able to increase costs, more people will become uninsured and/or fall into the Medicaid revolving door, and the socio-demographics of being uninsured will shift upwards.

But because we will already have “done” health reform, we won’t have the political will to do it properly when the chickens keep coming home to roost in a few years.

And eventually, we’ll have to go to Medicare for all with de-facto price setting and limited global budgets, and it won’t be pretty. Nor will it be the best solution we could have.

CODA: You want to see opposition to Obama starting already? Former government welfare Queen Rick Scott—yes he of the Columbia/HCA business model of defrauding Medicare and hoping no one notices—has laughably launched a group called Conservatives against health care for poor people Patients Rights , and worse, is starring in his own ads! I guess at least you can’t call it a Great Right Wing Conspiracy when it’s only one guy!

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  3. no help, still only denial,,,,i am so ready to -oo00h- can’t say,,,, they have raised taxes on cigarettes to get ppl to quit smoking and are raising again next month one more dollar, all so they can better health care,,, well ,,, why not helping those that you and i both know qualify for health care and ssi ( I HAVE EPILEPSY,,have had since childhood) , AND START THERE!!!! if they use their brains , that alone will close alot of files and paperwork, hours, and overtime pay. stop throwing our case away only to make us keep re applying and using up more of their hours and our money. if i was in jail, i would get treatment and maybe even come out with the SSI that i know AND THE STATE of LOUISIANA knows i qualify for. it is way past time we get our bonuses, our health care, not the kind the think we should have to cut down the budget, if that is so , then why don’t they put us on their insurance policy, SHAME SHAME SHAME ON LOUISIANA, BOBBY JINDAL, SENATORS AND CONGRESS MEN WHO REPRESENT US. THEY OWE ME, I HAVE MEDICAL BILLS TO PAY,,, YOU KNOW WHAT,,, THEY HAVE MEDICAL BILLS TO PAY. SHAME SHAME SHAME,,,,,WHERE IS MY RECOVERY MONEY****NO I WILL NOT APPEAL, TAKING TOO MANY TAXES AS IT IS NOW,****welcome to the white house, just not mine. don’t send ppl to knock on my door to support your plan or any including jindal’s office. i will light up my cigarette and while they blow smoke one way at me i will blow mine in their face. then they can run back and use their good ole’ high price insurance you help to provide for them to get treated by their doctor from smoke inhalation. i have no insurance to use to get treated for the smoke they blew up me. your office never responds to my e-mails of concern, ABOUT MY HEALTH PROBLEMS BEING AN EPILEPTIC TRYING TO GET PROPER CARE, so don’t ask me to support something YOU WANT!!!!! WHEN YOU CANNOT TAKE THE TIME TO SUPPORT OR CONCERN YOURSELF WITH SOMETHING I NEED. until then, that shows me how much my state, gov,city, and the U.S. cares about me , i WILL KEEP SMOKING. YOU TAKE 2,497.2 MG OF MEDICATION ***EVERYDAY***AND BE TURNED DOWN FOR SSI AFTER THEY QUALIFIED YOU FOR ABOUT 17 YRS, AND NOW SAY YOU DO NOT, MY BOYFRIENDS EITHER MAKES TOO MUCH MONEY OR I AM NOT CONSIDERED DISABLED ENOUGH. WELL I HAVE ALREADY HAD TO HAVE 17-19 STAPLES IN THE RIGHT SIDE OF MY HEAD FOR ALMOST 6 WKS A FEW YRS AGO DUE TO A SEIZURE. I HAVE ****EPILEPSY******NO CURE******WHY DO I HAVE TO BE PUNISHED FOR THE MONEY MY BOYFRIEND WORKS FOR, HE SUPPORTS ME AND MY KIDS, THAT IS MORE THAN MY COUNTRY IS DOING FOR ME. SUCH HYPOCRITS, ALL, YOU PAY MY DEBT. OF OVER 9,000 IN JUST E.R. MEDICAL BILLS ACCUMULATED SINCE BEING CUT OFF OF SSI, AND TELL ME I DO NOT MEET THE NEEDS, REQUIREMENTS, NOT SEVERE ENOUGH, OR THE WORST TO ME MY BOYFRIEND ****NOT MY HUSBAND****MAKES TOO MUCH MONEY. THEY OWE ME BACK PAY, CURRENT PAY, COVERAGE OF ALL PAST AND PRESENT MEDICAL BILLS, EVEN IF THEY HAVE BEEN TURNED OVER TO AN ATTORNEY REP. THE HOSP. ,,,, IS THIS THE WAY MY COUNTRY, MY STATE, THE TWISTED LAWS AND LOOPHOLES HELP ME,, WELL, NO WONDER SO MANY PPL ARE ON ANTI-DEPRESSANTS OR COMMIT SUICIDE, WE CAN’T GET HELP. TOO OLD FOR ONE THING, OR TOO YOUNG FOR THE OTHER, BOY, BOY, I GIVE IT TO THIS COUNTRY, YA’LL PLAY IT GOOD, AND I DID NOT SAY MANAGE , I SAID PLAY. THAT IS ALL WE ARE , A GAME, SOMETHING TO SHUFFLE AROUND SO LONG AS THE PERSON WHO GETS IT CAN HURRY UP AND PASS IT TO SOMEONE ELSE, SO THEY DON’T HAVE TO CONCERN THEIR SELVES WITH OUR PETTY PROBLEMS,, WHAT ARE WE –COOTIES– WELL, THEN DON’T ASK FOR OUR TAXES.WHILE I GET DENIED, YOU GET BONUSES, EARMARKS, DONATIONS,ETC..WELL THE ONLY DONATION I CAN AFFORD TO GIVE IS A ROLL OF TOILET PAPER.

  4. no help, still only denial,,,,i am so ready to -oo00h- can’t say,,,, they have raised taxes on cigarettes to get ppl to quit smoking and are raising again next month one more dollar, all so they can better health care,,, well ,,, why not helping those that you and i both know qualify for health care and ssi ( I HAVE EPILEPSY,,have had since childhood) , AND START THERE!!!! if they use their brains , that alone will close alot of files and paperwork, hours, and overtime pay. stop throwing our case away only to make us keep re applying and using up more of their hours and our money. if i was in jail, i would get treatment and maybe even come out with the SSI that i know AND THE STATE of LOUISIANA knows i qualify for. it is way past time we get our bonuses, our health care, not the kind the think we should have to cut down the budget, if that is so , then why don’t they put us on their insurance policy, SHAME SHAME SHAME ON LOUISIANA, BOBBY JINDAL, SENATORS AND CONGRESS MEN WHO REPRESENT US. THEY OWE ME, I HAVE MEDICAL BILLS TO PAY,,, YOU KNOW WHAT,,, THEY HAVE MEDICAL BILLS TO PAY. SHAME SHAME SHAME,,,,,WHERE IS MY RECOVERY MONEY****NO I WILL NOT APPEAL, TAKING TOO MANY TAXES AS IT IS NOW,****welcome to the white house, just not mine. don’t send ppl to knock on my door to support your plan or any including jindal’s office. i will light up my cigarette and while they blow smoke one way at me i will blow mine in their face. then they can run back and use their good ole’ high price insurance you help to provide for them to get treated by their doctor from smoke inhalation. i have no insurance to use to get treated for the smoke they blew up me. your office never responds to my e-mails of concern, ABOUT MY HEALTH PROBLEMS BEING AN EPILEPTIC TRYING TO GET PROPER CARE, so don’t ask me to support something YOU WANT!!!!! WHEN YOU CANNOT TAKE THE TIME TO SUPPORT OR CONCERN YOURSELF WITH SOMETHING I NEED. until then, that shows me how much my state, gov,city, and the U.S. cares about me , i WILL KEEP SMOKING. YOU TAKE 2,497.2 MG OF MEDICATION ***EVERYDAY***AND BE TURNED DOWN FOR SSI AFTER THEY QUALIFIED YOU FOR ABOUT 17 YRS, AND NOW SAY YOU DO NOT, MY BOYFRIENDS EITHER MAKES TOO MUCH MONEY OR I AM NOT CONSIDERED DISABLED ENOUGH. WELL I HAVE ALREADY HAD TO HAVE 17-19 STAPLES IN THE RIGHT SIDE OF MY HEAD FOR ALMOST 6 WKS A FEW YRS AGO DUE TO A SEIZURE. I HAVE ****EPILEPSY******NO CURE******WHY DO I HAVE TO BE PUNISHED FOR THE MONEY MY BOYFRIEND WORKS FOR, HE SUPPORTS ME AND MY KIDS, THAT IS MORE THAN MY COUNTRY IS DOING FOR ME. SUCH HYPOCRITS, ALL, YOU PAY MY DEBT. OF OVER 9,000 IN JUST E.R. MEDICAL BILLS ACCUMULATED SINCE BEING CUT OFF OF SSI, AND TELL ME I DO NOT MEET THE NEEDS, REQUIREMENTS, NOT SEVERE ENOUGH, OR THE WORST TO ME MY BOYFRIEND ****NOT MY HUSBAND****MAKES TOO MUCH MONEY. THEY OWE ME BACK PAY, CURRENT PAY, COVERAGE OF ALL PAST AND PRESENT MEDICAL BILLS, EVEN IF THEY HAVE BEEN TURNED OVER TO AN ATTORNEY REP. THE HOSP. ,,,, IS THIS THE WAY MY COUNTRY, MY STATE, THE TWISTED LAWS AND LOOPHOLES HELP ME,, WELL, NO WONDER SO MANY PPL ARE ON ANTI-DEPRESSANTS OR COMMIT SUICIDE, WE CAN’T GET HELP. TOO OLD FOR ONE THING, OR TOO YOUNG FOR THE OTHER, BOY, BOY, I GIVE IT TO THIS COUNTRY, YA’LL PLAY IT GOOD, AND I DID NOT SAY MANAGE , I SAID PLAY. THAT IS ALL WE ARE , A GAME, SOMETHING TO SHUFFLE AROUND SO LONG AS THE PERSON WHO GETS IT CAN HURRY UP AND PASS IT TO SOMEONE ELSE, SO THEY DON’T HAVE TO CONCERN THEIR SELVES WITH OUR PETTY PROBLEMS,, WHAT ARE WE –COOTIES– WELL, THEN DON’T ASK FOR OUR TAXES.WHILE I GET DENIED, YOU GET BONUSES, EARMARKS, DONATIONS,ETC..WELL THE ONLY DONATION I CAN AFFORD TO GIVE IS A ROLL OF TOILET PAPER.

  5. An honest discussion of American Medicine is not complete without mentioning some responsibility on the patient’s side of the equation.
    A simple solution, and one that has a great deal of appeal to third party payers and cost containment experts in Medicare, is to deny medical care to those who display unhealthy behaviors such as smoking, drinking, eating fast food, maintaining an abnormal Body Mass Index, failing to excercise, or those who have a genetic predisposition towards certain disorders.
    Insurers and hospitals are also interested in denying care for those who are injured while engaging in risky activities such as driving while intoxicated, working with tools without proper training, riding a bicycle, or playing sports.
    The other obvious solution that Ms Maier has repeatedly hinted at and which is being given serious consideration by healthcare cognizetti, is to stop spending 90% of our healthcare dollars in the last weeks of life. This is especially egregious among the elderly population who as a demographic, hold more wealth than any other segment of society, yet are asked to pay very few taxes because they no longer earn wages. This is the elephant in the room. The net drain on our economy by the elderly is crushing this country -and Baby Boomers are just beginning to hit retirement age.
    Any reasonable and honest solution to American healthcare must consider withdrawing all benefits for the elderly once they cannot care for themselves. At some point all Americans must agree that it is outrageously selfish for a person with only a few years of feeble inactivity remaining, to demand the maximum effort from the medical community to sustain that life. There is no return on this investment.
    If instead, we were to liquidate the wealth of every physically feeble, non-productive person over the age of 68, it would free sufficient funds to pay for the healthcare of the over 50% of Americans who are so impoverished that they don’t pay any income tax. It would help sustain the healthcare of the millions of Americans who, through no fault of their own, are here illegally. It would pay for the hundreds of thousands of young, unemployed single mothers so that American can rebuild the foundation of its economic might, which has always been unemployed, single persons with children.
    We should each urge the new administration to move forward with these carefully considered, common-sense measures, as a first step to a Healthier Tomorrow.

  6. Addendum:
    The underlying issue among uninsured and underinsured persons is being poor. Until we commit our military to the War on Poverty we surely are doomed to fail.

  7. An honest discussion of American Medicine is not complete without mentioning some responsibility on the patient’s side of the equation.
    A simple solution, and one that has a great deal of appeal to third party payers and cost containment experts in Medicare, is to deny medical care to those who display unhealthy behaviors such as smoking, drinking, eating fast food, maintaining an abnormal Body Mass Index, failing to excercise, or those who have a genetic predisposition towards certain disorders.
    Insurers and hospitals are also interested in denying care for those who are injured while engaging in risky activities such as driving while intoxicated, working with tools without proper training, riding a bicycle, or playing sports.
    The other obvious solution that Ms Maier has repeatedly hinted at and which is being given serious consideration by healthcare cognizetti, is to stop spending 90% of our healthcare dollars in the last weeks of life. This is especially egregious among the elderly population who as a demographic, hold more wealth than any other segment of society, yet are asked to pay very few taxes because they no longer earn wages. This is the elephant in the room. The net drain on our economy by the elderly is crushing this country -and Baby Boomers are just beginning to hit retirement age.
    Any reasonable and honest solution to American healthcare must consider withdrawing all benefits for the elderly once they cannot care for themselves. At some point all Americans must agree that it is outrageously selfish for a person with only a few years of feeble inactivity remaining, to demand the maximum effort from the medical community to sustain that life. There is no return on this investment.
    If instead, we were to liquidate the wealth of every physically feeble, non-productive person over the age of 68, it would free sufficient funds to pay for the healthcare of the over 50% of Americans who are so impoverished that they don’t pay any income tax. It would help sustain the healthcare of the millions of Americans who, through no fault of their own, are here illegally. It would pay for the hundreds of thousands of young, unemployed single mothers so that American can rebuild the foundation of its economic might, which has always been unemployed, single persons with children.
    We should each urge the new administration to move forward with these carefully considered, common-sense measures, as a first step to a Healthier Tomorrow.

  8. I could not agree more with christopher george’s post above on P4P and the poor.
    To pretend we have reliable risk adjustment scores for differing patient characteristics is laughable.
    If P4P goes forward like many would like, it is almost certain that poorer, sicker, more complex patients will become black sheep that few physicians will want to care for. Why shoot yourself in the foot trying to help the most fragile patients when all you are doing is setting yourself up for lower “quality” scores, lower “physician rankings” and lower pay?
    In addition, good luck with the shared decision making movement under P4P. Why engage the patient in the decision and offer unbiased evidence about treatment decisions when that may lead to them choosing not to do what the “quality indicators” say they should do? Rather than saying “if you do x, your benefit could be y (and your harm could be z),” you will increasingly hear “it’s REALLY important for your health that you do x.”
    Why bring the patient into the decision if they might choose (appropriately) something other than what the “quality” measures say they should choose? Instead, bully the patient with a black/white description of the decision so your physician quality scores benefit. (This is not theoretical, I’m already seeing it happen and feeling pressure to do it myself)
    As maggie has pointed out, there is little black and white in medicine. It’s mostly grey.

  9. “How do you deny someone access to healthy habits”
    You subsidize high carb/fat and don’t subsidize fresh fruits and veggies. You also don’t ensure safe neighborhoods that encourage outdoor activities. The poor also live in old stock housing (lead paint) and more polluted neighborhoods. http://www.nhi.org/online/issues/95/lead.html
    I believe HUD had a program where the poor were paid for lead paint abatement of homes in their neighborhood, but that was cancelled.
    Yes the poor can make healthier decisions, like moving to better higher rent neighborhoods with health clubs they can join and spend their limited income on healthier, even organic foods.

  10. “I guess it’s easier to deny proper healthcare coverage to the poor at the same time you deny them access to healthy food/exercise habits.”
    Huh??? How do you deny someone access to healthy habits?

  11. Maggie,
    My growth numbers were purely illustrative, not meant as predictions.
    As for physician salary expectations being based on CEO salaries: on one level, I don’t give a rat’s patooty how many hundreds of thousands or millions CEOs or physicians think they deserve. I know many in both groups are milking the system to extract profits that don’t improve the economy or public health.
    By the way, if physicians are comparing themselves to CEOs and thinking they come up short, they are full of shit. The CEOs who get paid millions are almost all running huge corporations and only get to those salaries late in their careers. Also, Forbes does a comparison of the highest paid professions in America every year. As I recall, 9 of the top 10 were medical specialties. The only non-medical profession in the top 10 was CEO. It came in at number 8!
    I of course realize the enormous political power physicians and CEOs have, far out of proportion to their numbers, and that getting down to European income levels in either case is a long shot. But what is the blogosphere for if not to try to push the public debate forward and reset the Overton Window? (Yes, yes, it’s there to inform and entertain also.)

  12. Well, speaking of how to save $$, here’s an article in the New England Journal of Medicine that I read last night, regarding PCI (e.g. coronary angiography with stents) vs. medical therapy alone.
    Conclusions: “Our study adds to the evidence that in a variety of clinical situations involving patients with coronary artery disease IN STABLE CONDITION (caps mine), a strategy of routine revascularization (e.g. PCI) adds only a modest EARLY advantage with regard to symptoms and functional status, and this advantage is not maintained. Given that this modest quality-of-life benefit was obtained at a cost of more than $7000 per patient, our cost-effectiveness analysis showed that this strategy was not economically attractive. The analysis of lifetime cost-effectiveness in the COURAGE trial had similar results, with an estimated cost per additional QALY with PCI as compared with medical therapy alone of approximately $168,000.”
    Now, somebody smart like Maggie who knows how many PCI’s are done each year do the math, assuming a certain percentage of PCI’s ARE effective (patients with acute MI or acute coronary syndromes – maybe) and here’s how we can save big bucks with just one little intervention in one little specialty. And comparative effectiveness research is not a good idea?? Hmmmm…..
    (Reference: Mark, Daniel, et al; “Quality of life after late invasive therapy for occluded arteries” NEJM 2009; 360:774-83)

  13. Maggie,
    You are aware I am sure of the commodities wager that the limits to growth doomsayer Paul Erlich made with Julian Simon. I propose a similar wager regarding the “corrections” that P4P is going to make for patient condition. I bet the corrections will under correct and result in terrible finacial proplems in hospitals that care for the poor. This will be one more reason doctors can’t afford to take care of poor people.
    Next time you are at some swanky Manhatten establishment, ask yourself how many 450 lbs diabetics with ulcers and neuropathy are there among superrich women. Not many.
    Our clinics are filled with them.
    The fact of the matter is that we don’t really know how much more expensive it is to treat subgroups of patients. There are literally hundreds of confounding variables. Great data on the benefits of the aggressive treatment of CF. Lots of black holes in our knowledge, generally, though. The data is just not there.
    Extrapolating from an incomplete dataset will underrepresent outliers. In medicine, as elsewhere, outliers dominate total cost. Simpson’s paradox will confound the largely babe-in-the-woods regulators. Idealogically pure, but light in the loafers where mathmatics is concerned. I know a few famous ones from the Boston area. I know you don’t want to believe any of this…
    So, here is my wager..In spite of the so called corrections for clinical conditions, P4P is going to be a disaster for charity hospitals and doctors who work there.
    I wish I could share your optumism. We need much much less care. We will go bankrupt before we address the real problems. The poor need more care, and the rich and the old need far far less care. This P4P is not going to help.

  14. The poor and obesity;
    http://www.msnbc.msn.com/id/9505511/
    Interesting trend map.
    http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/
    http://www.msnbc.msn.com/id/20461564/
    “The five poorest states were all in the top 10 when it came to obesity rates.”
    So much for low wage policies.
    “An exception to that rule was the District of Columbia and New Mexico. Both had high poverty rates, but also one of the lower obesity rates among adults.”
    So, how did these states do it?
    I guess it’s easier to deny proper healthcare coverage to the poor at the same time you deny them access to healthy food/exercise habits. Think we’d ever bail out the poor like we bailout investment bankers and their bonuses? If you think bailing out the poor is a black hole, what about GM, housing, etc.?

  15. On GDP growth adn health care cost–
    GDP will not be growing by 5 percent–or anything close to that. Right now, (recent months) it’s negative.
    By the end of this year it may stil be negative–or flat.
    Economists expect very slow growth for the foreseeable future (2% to 3%)
    The CBO has modeled growth of health care spending and GDP growth.
    The Commonwealth Fund also has done some very honest calculations. (see my post on their report on http://www.healthbeatblog.org). Even with seroius cost savings–including paying docs dignificantly less to pay for Medicare patients (and Medicare for all patients) than private insurers pay, Commonwealth projects health care spending will continue to climb significantly faster than GDP.
    I think we can bring health care inflation down to GDP growth, but it is going to take some time to do this– adn it’s going to require doing things that many will not like.

  16. Thanks again for your comments.
    On Kaiser– When quality is measured at Kaiser compared to other health centers and hopsitals, of course, they
    adjust for age, race, and underlying health of population.
    See the Dartmouth reserach –they have been doing this for nearly 3 decadies and, no surprise, have figured out that some health care providers see healthier patients than others. (www.dartmouthatlas.org)
    Malpractice awards have been growing steeply in some other countries (growing faster than in US) — but overtreatment isn’t growing. This undermines that argument that malpractice stands at heart of heart of
    overtreatment.
    j.d. –thanks for your thoughtful comment. But . . .
    When Matthew rails against putting more money into the system, he ignores the fact that we will be insuring mnay more people–ht uninsured and the underinsured (people with cheap, high deductible policies who cannot afford to use them.)
    Many of these people are poor.
    The poor are much sicker than the rest of us.
    The poor are much more likely to suffer from mental
    illness (being poor is extremely stressful) depression, anxiety.
    The poor are much more likely to self-medicate– drugs, alcohol, and tobacco to calm nerves.
    The poor are more likely to be obsese, for various reasons.
    These problems are all very hard to treat. By giving the poor (uninsured and underinsured) access to more care we will help them—but we won’t “cure them” of being poor. If you live in the Bronx, air quality in the buildings there means you are much more likely to suffer from respiratory disasee.
    We are only somewhat successful in helping alcoholics and drug addcits. (AA works for some people; not for others.) We are not very successful in helping truly obese people take weight off–and keep it off.
    Finally, the poor tend to be not very compliant patients. (Not well eduated, they may have a time reading instructions, remembering instructions. Some speak little or no English. Lives are chaotic, etc.
    Bottom line: Even though we aboslutely should provide healthcare for the poor, they are always going to be sicker and more epensive to care for than the rest of the population. (Their real problem is not lack of access to medical care; their real problem is poverty.)
    Alcoholics who would have died, without medical care, at age 55 wiil with medical care, live to 78. Some will stop drinking at 75 (body just can’t take it any more); others won’t.
    This is why it will cost more money to Cover Everyone.
    The other reason health reform will cost more is that we have to spend money to raise the Quality of care.
    Right now, the quality of much U.S. healthcare is pretty low. We need health IT to reduce errors–very expensive.
    The CBO has modeled possible savings–Peter Orszag is skepitical IT will save money–maybe, maybe after 10 or 15 years it will save some, not a lot. But it will improve quality, so we have to do it.
    Compative effectivenss reserach will cost money at the outset–savings come later.
    We need to invest far more in palliative care, primary care, preventive care and chronic disease management
    We also desperately need a larger investment in public health.
    These are just some of the reasos why higher qualtiy universal coverage (the goal of reform) will take more money than we spend now.
    We can, as Obama said, find “part” of the money we need by squeezing waste out of the system.
    But we can’t find all of the money we need. Some of the “waste” cannot be removed for cultural reasons.
    Many Americans believe that we should “do everything possible” to keep a dying person alive as long as possible. This is very expensive. (Many Europeans have a different attitude toward death.)
    Keep in mind that this is religous issue for many people.
    Also U.S. doctors earn much more than doctors in Europe–even after adjusting for cost-of-living. This is in large part because CEOS in the U.S. earn such astronomical salaries (not so in Europe)
    U.S. CEOs have set the bar very high for what counts as a “reasonable” salary for professoinals in the US.
    We’re not going to get doctors now earning $800,000 to settle for $200,000. We can shave fees, yes, but US
    doctors are always going to expect to earn more than French doctors.
    But probably the biggest difference is this:
    the U.S. has many, many more desperately poor people than European countires that are largely middle-class.
    We have decided (rightly) that we should start giving those poor people access to care. This is good. But it will be very costly. And giving them medical care will not lift them out of poverty. (If we gave them education and medical care and excellent drug counseling, family counseling etc. we could launch a war in poverty, as in the 1960s, and actually reduce poverty (as we did then).
    But taxes on the wealthy were much higher then.
    If you think Matthew is unhappy now . ..
    Matthew rarely writes about the poor and the problem of poverty in the U.S. I wish he would. . .I’d be interested in his take.

  17. jd – That’s a good summary of the task at hand. I would tie #1 and #2 together by saying that we need to inject some social responsilbiity into the equation. Many of our healthcare problems are exacerbated by greater societal problems. There is no sense of a greater good out there, or at least it’s not pervasive. Physicians, insurance companies, patients, etc. are only looking out for themselves.
    We need someone (I’m assuming it needs to be Obama) to stand in front of the American public and tell us that we are all in this mess together, we have all contributed to it, and we will not effectively get out of it unless we ALL contribute to the reform effort. I think Obama knows he needs to do that, and I think he has made a half-hearted attempt, but he has not had that hard hitting conversation that needs to be had. I don’t think he would be jeopardizing his political future by doing so. I think he would be one of the top presidents of our time if he did so.

  18. I think in the (apparent) disagreement Matt and I have with Maggie, we need to keep some things straight and I’m not sure that they consistently are.
    I completely agree with Matt that there is no good reason why Americans should be asked to contribute anything more to the health care system…as long as that means: in the long run, and as a percent of GDP. I would go a step further and say there is no good reason why our contribution (through premiums, taxes and out-of-pocket payments combined) shouldn’t go down by at least 15%, resulting in a share of something like 14% of GDP (still the highest in the world).
    But I also completely agree with Maggie that the needed reforms will be complex and piecemeal, with no silver bullets, and we can expect costs to increase in the short run–nominally, in real terms, and even (briefly) as a percent of GDP.
    I think it’s really important to remember when talking in this big-picture way about costs that it is possible to have costs increase in real terms and yet decrease as a share of GDP. If inflation is 3%, productivity growth is 1% and population growth is 1%, then GDP growth will be a little over 5% that year (am I getting that right, economists?). If health care costs go up by 4%, they will outpace inflation and thus go up in real terms, but they will go up less than GDP growth and thus decline as a share of GDP. I think hitting that sweet spot should be the goal.
    This gradual trajectory will reduce or avoid problems (such as mass layoffs) that Maggie described, and which must be avoided during this severe recession. It will also reduce the opposition of the provider/supplier lobbies. Opposition will still be fierce, of course.
    I think we can all agree on the following:
    1. Reforming health care is a difficult, complex undertaking and it will take years to achieve sustainable cost trends in the medical sector, and many hard-fought battles. Universal health insurance is actually far easier to tackle.
    2. The battles on reform will not be won until the public supports reform, and to do that it must understand (however superficially) the major drivers of excessive cost, and just how vast is the gulf between an efficient, high-value system and the one we have.
    As an aside, I would really like to see someone do an analysis of what would be gained by reducing the spend on health care by, say, $400 billion (roughly what it would take to get us to 14% of GDP for health care today).
    Where would that money go, how would it be distributed? How much more productive would that money be when spent on other sectors of the economy? What about the productivity and quality of life impact from removing millions of unnecessary hours that people spend going to the doctor, reading 6 month-old tattered Time magazines covered in rhinoviruses while in the waiting room, wearing paper robes that continually make you feel like you are exposing yourself in public, then undergoing unpleasant procedures some of which actually cause you more pain and damage than you went in with?
    If anyone has seen a good analysis of that impact on growth, productivity and quality of life, please post it. Saving $400 billion dollars, as great as that is, would be worth far more than just saving $400 billion dollars.

  19. I’ve had excellent luck with Kaiser in the DC area for more than 20 years.
    I’ve liked some doctors, disliked others – but they’ve all done what they were supposed to and I’m still here in fine health to tell the tale. However, they are not cheap! Our family plan is well over $15K a year for the low deductible coverage.
    People fall into camps about places like the VA, Kaiser, etc… Nobody wants to be told what they’ll do or who they’ll see. I think choice is very important in any reform.

  20. Maggie – Outstanding post! That’s the kind of substantive discussion we need. The solutions you’ve outlined are right on track in my mind. Too many people are suggesting superficial solutions, which is typical when government is expected to fix things.
    As I posted on your blog, we need to ask ourselves how we feel about the effectiveness and efficiency of our government over the last 15-20 years before we turn the keys to the healthcare system over to them.

  21. In the DC area when my brother was there, Kaiser was paying pediatricians less than fellows. Everyone who could left. That was 15 years ago.
    Since most clinic patients are well, it is easy to keep them happy on a survey, usually by gasp! the same overtreatment that is a problem with private patients that are sick. Actually, I would bet that overtesting and overtreatment of the worried well in clinics exceeds overtreatment in actually sick patients. There are a lot more of them, for one thing.
    For sick patients in the Kaiser system, the problem is the opposite — getting the attention of someone knowledgable with the problem. Since sick patients are thankfully rare, this doesn’t hurt their ratings, evidently.
    When my brother was there, hospital rounds were considered an unwelcome add on to a clinic job.
    This is another variation of selection bias that poisons Pay for Performance. The poor tend to smoke, be obese, and have poor outcomes, regardless of care. Kaiser patients are younger, healthier, and employed. That helps outcomes, independant of care.( The policy wonks were probably studying film in college, not Bayes Theorm.)
    This is something to keep in mind when you evaluate surveys.
    Maggie, I think you will find that many “popular” tests and procedures are instigated by activist patients who will not take no for an answer. If you are around some morning at 3 am, you take a stab at talking a patient out of insisting on a CT scan for trivial head trauma!
    I continue to be amazed that no mention of litigation reform in a discussion of utilization reform. We have a woman here in my area…she is 27..she gets frequent bouts of shortness of breath..she has been seen about 6 area hospitals, by dozens of ER doctors. To evaluate for a rare condition, a blood clot, she has had 25? CT scans of her chest. (I will be astounded if she doesn’t get breast or throid cancer.) Few people want to risk personal bankrupcy from a lawsuit from the unlikely possibility that this time she really does have it.
    It must be irresistable to find a pecuniary motive behind all doctor decisions, but ER doctors don’t make a dime ordering CT scans.
    Another point not often mentioned: Preventive care is a belief, like believing in good luck from a rabitts foot not “evidence based”. Most studies looking at preventative care have found that outside of a few simple things, it is not very cost effective. Analysis of the yearly physical, the pre-operative chest x-ray, PSA, screening ovaries for cancer in high risk groups has been not proven very helpful.
    The truth is we don’t know a lot about preventative medicine. If you are really sick we can help you. Most preventative measures can be done without a doctor, or if done with a doctor yield no better results. Think weight loss, smoking cessation, any number of mental conditions..
    Preventative care is a political belief to some degree, which wonks often hold, becuase they like the idea that it is helpful. Holders of this belief don’t like intensive medicine, which is an opposite belief, also only supported by the scantest of evidence. The most aggressive cardiology care is slighly less effective than just not smoking. Not smoking is a lifestyle choice over which doctors have little influence, so don’t try to classify that as “preventative care”.
    What we realy need is less of ALL care; it won’t happen without tort reform. Enterprise liability is not tort reform, it is rather an annuity paid by society to the tort bar. Everyone wants to change the system while keeping some part which they see as personally benefiting themselves the same. Insurers want to get rich. Lawyers want to get super rich. Reformers don’t want to piss off the hand that feeds them, even if it dooms their larger purpose. Politics does make for strange bedfellows.
    Based on this blog, where only an occasional doctor has even mentioned the topic – not even to dismiss it..,we will go a long long time before healthcare mess is addressed.

  22. Matthew–
    Yes, my comments was looooong. But, in case you don’t read all of your reader’s comments on THCB,
    here are too of the final comments on that thread regarding “The Presiddent’s Budget”
    “This is one of the best discussions I’ve seen on the THCB. Great comments on all sides. I’ve read all the comments completely through and hope all do the same.”
    and “Great comments and thread.”
    I have to say I am impressed by the fact that even people who disagree with me were respectful, making intelligent detailed arguments . . . .
    Just saying “no that isn’t true” (because I say it isn’t true” really doesn’t count as an argument.
    Finally, with regard to Bob’s piece (and I like Bob too, but don’t always agree)
    as I think you know, the biggest savings in Medicare will come from changing what it covers–and that will
    be done, to a large degree, by revising the physicians’ fee schedule.
    Right now, the law says that the fees Medicare pays physicians should be slashed, across the board, by 20 percent on January 1, 2010.
    We know that won’t happen; it a crude solution, which Congress keeps deferring these cuts (that now add up to 20 percent).
    The fee schedule has to be revised with a scalpel, not an axe. As the Medicare Payment Commmisssion has said , these fees must be revised in a “budget neutral way”–raising fees for primary care docs etc at the bottom and slicing fees for certain services–often of minimal value– at the top.
    (Why raise any fees? Becuase the point of healthcare reform is to RAISE THE QUALITY OF CARE while simultaneously controlling costs and covering everyone.
    We dont’ have enough primary care docs in part because they are paid so little: as a result, we don’t have enough preventive care and chronic dissease management.)
    Right now, the fee schedule decides how much to pay based on how much is COSTS the doctor –in terms of time, physical effort, mental effort, etc.
    MedPac has suggested that perhaps the fee schedule also should reflect “benefit to the patient.”
    The Century Foundation’s Working Group on Medicare Reform agrees. People like Peter Orszag agree. Recent CBO reports suggest the CBO agrees.
    But it is not the President’s job to sit down, look at the thousands of medical services and decide where to make thousands of cuts and hikes in fees..
    The RUC does that, and while I have criticized this group in the past, this time they know there will be much public scrutiny. They would be expected to use the comparative effectivenss reserach that we already have.
    Insiders tell me that many in the group realize that they are going to have to make some tough decisions.
    (The alternative is that 20 percent cut looming over them.)
    Finally, you might well ask, if they adjust fees in a “budget neutral way” how will this save money?
    Because when they reduce the fee for a formerly very lucrative service, you’re going to see many, many fewer of those tests or procedures done. Bottom line: less overtreatment and savings to Medicare.
    In addition, it is very likely that Medicare is going to hike co-pays for procedures that are no more effective than a less expensive alternative. (Recently, they did this with virtual colonoscopies.)
    Very likely someone will try to fight this in court, but given the financial crisis, I suspect Medicare will win.
    Like lower fees, higher co-pays will steer patients away from the most expensive, less effective treatments.
    Finally, I expect that Medicare is going to begin saying “no” to many new tests and treatments–even if approved by FDA (which will be getting tougher) unless there is good medical evidnece showing that these new treatmetns are more effective for patients who meet a particular profile (and then Medicare will pay only for those patients.)
    It’s hard to say “no” to popular treatments that doctors are already doing (though really hiking oc-pays will have an effect) but not so hard to say no to something that isn’t already out there. Insurers will follow whatever Medicare is doing.
    Finally, making these decision–adjusting the fee schedule, adjusting co-pays– all of this is detailed work that will takee time.
    Read the two CBO reports from December (around 400 pages) that Bob L. has written about (see his post on his blog titled “Naive Reformers Need Not Apply”) plus the CBO January report. As these reports say: “There is no single silver bullet–or 10 silver bullets. There are more than a hundred options for saving money under Medicare that CBO discusses– many reap small savings, a few, like giving the compaartive research financial teeth, coule reep substantial savings.
    Together, they will make Medicare affordable and sustainable.
    You’re expecting Obama to come up with a simple,quick fix for a extraordinarily complicated problem.
    And by the way, instead of hammering away at the fact that he is raising taxes –could you mention that he is raising taxes for the wealthiest 1.8% of the population, while lower taxes for 95 percent of all Americans?
    I know, I know, when you get into detail like that,your comments become loooooong . . but for the sake of accuracy, it really is worth it.

  23. “If we achieved the real issue behind health reform—getting everyone covered in a single social insurance pool. Because if we did that first thing, we could fix everything else later.
    But instead we’re going to get some mealy-mouthed version of pay or play….”
    I agree wholeheartedly. And I’m very much afraid your forecast is right: Too little and too late. It’s disheartening, with so many people needing help right now. And I don’t really see anything in these plans that is going to address the rising underground economy — all of those people who are struggling to make ends meet by working part-time jobs, freelancing, “consulting,” temping and other work that makes you too well off to get government aid but not rich enough to afford private insurance (if you can qualify for it).

  24. “It’s really not much more than redistributing $$.”
    Deron, our entire economic system is all about “redistributing $$”.
    When universal coverage in single pool is done with universal budget then you’ll see real reform at lowering costs. And yes that will be taking dollars from one pocket and putting it in another pocket – hopefully to the patient/premium payer/taxpayer and from insurance companies/specialists/drug companies/hospitals/device makers/etc. Patients are going to have to live with utilization restrictions as well.

  25. Mike, at least in the health policy world Kaiser is cited all the time. Not so much in the more popular debate, because Kaiser hasn’t in the past been associated with research at the bleeding edge of medicine in the same way that Mayo and Cleveland Clinic have been. Those two are cited more not because they do a better job at the day-to-day level but because they have a brand the public is aware of based on new transplant techniques, etc.
    As for bev M.D.s comments, Kaiser has the highest rating among all health plans both for quality of preventive care and member satisfaction in the latest California Dept. of the Patient Advocate review: http://www.opa.ca.gov/report_card/hmorating.aspx
    As for the pros and cons for a doc to practice there, here is a nice review (found on Google just now, have no idea who this person is): http://cancerdoc.blogspot.com/2005/06/is-kaiser-model.html
    Full disclosure (anonymous-style): I have a close connection at Kaiser.

  26. Mike;
    My experience with dealing with Kaiser doctors as a non-Kaiser doc is several years old. However, at that time a number of the docs on our medical staff were Kaiser refugees. They apparently made their docs see way too many patients/day as well as other mistreatment. The non-Kaiser docs hated them because Kaiser would not provide specialists for ER call, but would then take the patient (and the fees) away the next morning, after the non-K doc had been up all night caring for them. As a pathologist, if I tried to call a Kaiser doc with an unexpected pathologic finding like an unexpected cancer in a uterus they had removed, I would be told that doc was “off” that day, or that the patient’s care had been rotated to another doc. This new doc knew nothing about the patient, so I was the one telling him about his own patient! A secretary in our office was a Kaiser member and they went to great lengths to prevent her sick kids from coming in to see a doctor. This is dangerous in pediatrics since kids may go bad VERY fast.
    Maybe they’ve improved since then, but I would never have Kaiser insurance myself. I think the Cleveland/Mayo/Geisinger people are a cut above – others may know why better than I, but I suspect it is the academic perspective.

  27. Sebelius and Deparl, and anyone else interested in making a go of health reform should take a look at a new book “Disease, Diagnoses and Dollars” by Bob Kaplan at UCLA – The book argues that too much healthcare is not only costing us money – it may be making us sick.

  28. Mike – I can’t comment on Kaiser, but here on the east coast, Geisinger is looking pretty good as an integrated model. They’ve been quietly tackling reform for quite some time, while everyone else bickers about how we’re going to cover the uninsured.
    Matthew – We could debate this for years and years, but I think you know that universal coverage in a single pool is not reform in and of itself. It’s really not much more than redistributing $$. I’m not saying I’m against it, but it is far from real reform. Until you address the reasons why the sick people going in the pool got sick in the first place, you will be doing nothing more than treading water.

  29. I realize that this is a simplistic question, but why isn’t the Kaiser model ever considered as the solution for mainstream cost-effective, integrated health care? Experts always refer to the Mayo Clinic and Cleveland Clinic as effective models of vertically-integrated multi-specialty group practices. Is the Kaiser experience that bad in California?

  30. It’s hard to make deep cuts. Every state has hospitals which employee a lot of people. If hospitals constitute 1/3 of costs, it seems logical that the government can cut costs by cutting payments to hospitals. But when you do this, what do you expect hospitals to do? They’ll obviously lay off workers and reduce quality of care. Lessons of the Balanced Budget Act of 1997.
    Right now, given that the country is approaching 10+% unemployment rate, setting up policies that lead to even more layoffs will not win votes.
    A lot of healthcare policy folks and economists are living above the clouds. Assume the can-opener.

  31. Hmm If two men had been appointed would you have made a note of that? Not sexist per se but perhaps from an older era?
    We often know when something is the exception to the norm when we call it out by modifying it or explaining it. I still remember 20 years ago when other residents were referred to as “female doctors” and people thought that meant a gynecologist (they were in fact internists and surgeons who were female).
    When you add an adverb to a noun to modify it you clearly are stating that this is an exception to the rule. Same with “male nurses” it implies that nurses are female by default.

  32. Sorry, the word “opposted” should be “opposed.” Poor proofreading on my part.

  33. Matthew;
    LOL re Maggie and the long comment – but that’s actually plural; I counted at least three. Lesson I learned was, don’t cross Maggie on any subject! (:
    I wanted to comment on your point #3: why DOES Obama leave details to Congress? He supposedly let Nancy Pelosi do the bailout bill, and we all see its weaknesses. If letting Congress flesh out the details of his goals is his idea of “inclusiveness”, I fear he is terrifyingly naive about their own priorities, as opposted to his. Hopefully, he will learn quickly – his learning curve affects all of us.

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