Matthew Holt

Time to put aside the intellectual disputes for now

It’s always fun to see my friends beating each other up in public….and if you read down in the comments on the post published yesterday you’ll see a significant dispute between Maggie Mahar and the Klepper/Kibbe/Lazsweski/Enthoven team (who I’m calling the Four Horsemen from now on). But I think that right now we need to change what we’re talking about.

I’m with Maggie in that there is potentially more in terms of changing the payment system in the current bills than nothing, but it’s not that much more than nothing. However, pressure from the the Four Horsemen and their fellow travelers on payment reform may increase that section of the bill as it gets worked out on the floor and in the Congress conference committee. Their pressure will also serve notice that aware, sensible people are looking at the issues of payment and delivery reform.

And at the least, the proposals in the bill don’t make the current delivery system any worse (other than the exemption from taxes for self-insured groups which clearly discriminates against integrated systems and must go).

Instead lets focus on what most of the bill consists of  which is insurance reforms:

  • Yes, they take way too long to be implemented (They’re starting in 2013? Why not 2011 or even middle of 2010?).
  • Yes, the subsidies are too low–and it would be better if we had one tax-based insurance pool
  • Yes there should be national, highly regulated, insurance regulation with everyone (or many more people) having access to a real exchange
  • And yes if there is a public plan lets have it available everywhere to keep the private guys honest (even if its just more access to Medicare as Jeff Goldsmith suggests).

But what we’re going to get from the bills in Congress now is clearly better for poor and lower income people with health problems, and for small employers, than the alternative. The alternative is nothing this year, and probably nothing for a good long while after that. And those are the people the current system discriminates against the most.

I appreciate that what may pass the Congress is not what any of us Obama fans and Democrats would want in an ideal world. Yes, all of us would like serious campaign finance reform. Yes, I think we’re all appalled by the behavior of the unions and the large employers in stopping meaningful tax reform on health benefits. (Jeez, I even agree with Mark Pauly about one way out of  that!)

But I remind you of the two rules for health reform I discussed a while back (and which Uwe Rheinhardt echoed in his three priniciples).

Rule 1 A health care reform bill needs to guarantee that no one should find themselves unable to get care simply because they cannot afford it. Neither should anyone find themselves financially compromised (or worse) because they have received care.

Rule 2 A health care reform bill needs to limit the amount of GDP that is going to health care to its current level, with an overall aim of reducing the share of health care going to GDP.

I think that the likely bill goes some long way towards the objectives in Rule 1. And makes a small start, albeit a very trivial, one towards the objectives of Rule 2–although I appreciate that it runs a substantial risk of breaking Rule 2. But I think that Rule 1 is more important than Rule 2–for now.

Maggie’s advocacy of the current bill fits Rule 1. The pressure from the Four Horsemen, Peter Orszag, Don Berwick, Zeke Emmanuel and others can hopefully make the Congress aware that on Rule 2 there’s lots of work to be done.

And I remind you all of perhaps the best post I ever wrote on THCB back in 2005. It was called “Why Hillarycare failed…and what we need to learn from that failure.”  Here was my conlclusion:

The main lesson of HillaryCare is that when the right moment comes along politically we need to get whatever form of universal reform can be agreed on shoved quickly through the Congress. Make no mistake, universal insurance is a big bang and a necessary big bang. Getting it through will be a hell of a confluence of opportunity and tactics. Once we get it done, then we have a while to worry about sorting out the system to the purists’ satisfaction later.

So will you all still please stop arguing about what it should look like!

I know that the bill in Congress now isn’t universal insurance–but it’s as close as we’re going to get for now. So let’s stop arguing and instead get as much pressure as possible on getting the right stuff that we agree on into the bill. And when I say “we” I don’t mean a bipartisan 80% we, I mean the Dartmouth loving, primary-care loving, universal pool approving readers & authors of THCB. A group which includes both Maggie and the Four Horseman. And me.

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Categories: Matthew Holt

79 replies »

  1. Wow, I think this pretty much defines liberal elitism…
    “And when I say “we” I don’t mean a bipartisan 80% we, I mean the Dartmouth loving, primary-care loving, universal pool approving readers & authors of THCB. A group which includes both Maggie and the Four Horseman. And me.”

  2. Bev, I can’t really fault the en masse move to a new treatment that seems logical to everybody. It would be maybe immoral to not do so. However, when it becomes evident that the new treatment is no better than the old and cheaper one, is there a parallel en masse movement back? If not, this is probably where payment reform should step in.

  3. Margalit;
    Your point is well taken of course, but rather than doing “a lot of” something new, what happens is that the docs just switch en masse from the old treatment to the new treatment. Witness, the articles regarding medical treatment vs. stenting for stable coronary disease. Because stenting was new and sexy, reimbursed better, and seemed logical to both drs and patients (e.g. if you physically open an artery, wouldn’t that obviously have a better outcome than treating with medical therapy? turns out it didn’t); there was an incredible exponential increase in stent procedures in a short period of time.
    It is this unsupported mass migration to the “new” that payment reform and more thoughtful and timely comparative effectiveness studies would provide. What if, for instance, everyone receiving the new treatment was required to be on a study protocol? That would accumulate the evidence much faster. (just throwing that out off the top of my head.)

  4. Just to play devil’s advocate, if something new comes out and you don’t do a lot of it, how do you study comparative effectiveness over time?

  5. Bev M.D.,
    Thanks very much. That’s very helpful. I think it would be interesting to look at the trend in the number of coronary angiography studies that have been done in recent years and the percentage of those that led to stent insertions or referrals for a CABG.

  6. Barry;
    I had a very difficult time finding one review reference that would address the scope of your questions regarding the efficacy of stents. I think there is no question that in a patient presenting in an unstable situation (so called acute coronary syndrome as well as myocardial infarction with or without characteristic EKG changes), percutaneous coronary intervention (PCI) with stenting is beneficial. The controversy lies with patients having stable coronary disease, such as stable angina. Here is what I could find, of recent origin, regarding that (I THINK these links will work):
    NEJM — Effect of PCI on Quality of Life in Patients with Stable Coronary Disease
    NEJM — Optimal Medical Therapy with or without PCI for Stable Coronary Disease
    One on the risks of drug-eluting stents:
    NEJM — Unanswered Questions — Drug-Eluting Stents and the Risk of Late Thrombosis
    And here is one on stents vs. CABG:
    NEJM — Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease
    As far as can you tell ahead of time who needs stenting and who doesn’t, I would defer to your cardiologist to answer that specific question. My guess is mostly yes, but this is far away from my specialty.
    I think the gross over-stenting of patients in the early years has now abated due to the newly discovered side effects and comparative effectiveness research noted above. However, it provides a valuable historical lesson on medical knowledge, medical faddism, fee for service medicine, and other issues of current interest.

  7. Ughhh…I don’t want to disagree again, Maggie 🙂
    The literal translation from Hebrew is “When I am for myself, what am I?”
    The common commentaries explain this as a moral question as to one’s role in the world or in society considering that one has to also be able to take care of himself. It’s a question regarding the balance between self interests and social responsibility.
    At least that’s what I learned in school….. 🙂

  8. Barry;
    I will try to assemble the references for you regarding stents. As I said, this is not my specialty, but I have been reading about it in the NEJM. I will see if there is a review article that may summarize it all and get back to you.
    Interestingly, there has been some evidence to suggest that some patients are getting stented who may benefit more from cardiac bypass. I will try to find that too.

  9. Mike–
    A gret comment on narrow self-interest. Just a tiny addition Hillel said “If I am only for myself WHAT am I?”
    The man who is totally self-interested is no longer a who, he is a “what.”

  10. I agree with Mike. Again.
    Interesting you guys are talking about stents and possible over-use. Did any of you see “Money Driven Medicine?” The interventional cardiologist in the film said “When you’re a hammer, everything looks like a nail.”

  11. Bev M.D.,
    As you pointed out in a prior comment, patients who receive stents, especially the drug eluting type, are likely to be on Plavix indefinitely. That includes me. As it happens, I also take the small (81.25 mg) aspirin each day.
    As I’m sure you know, when interventional cardiologists find a significant blockage during angiography, the team is already there and a stent can be inserted in about 15 minutes. While there may be unnecessary stent procedures, there are also less than half as many CABG operations performed now than there were 10 years ago when I had mine. Moreover, even if stents don’t extend life for many patients, they often significantly increase the quality of life by reducing the incidence of angina which causes plenty of anxiety in heart patients as well as discomfort. It’s hard to put a value on that.
    I would like to know more about how easy it is to distinguish among patients who need these procedures and those who don’t before the fact. If it’s a relatively easy matter to determine, perhaps there should be more post procedure audits to see how many are unnecessary, which specific doctors are performing disproportionate numbers of unneeded procedures, and then sanctioning them appropriately. While there are certainly risks associated with angiography, stents, and CABG operations, the potential adverse consequences of treatment that is too conservative (medication plus a sensible diet and exercise regimen) for too long can also be severe. It’s different from trying physical therapy before resorting to back surgery or putting off that hip or knee replacement for another six months. Those conditions are not life threatening.
    Regarding the hospitals, it’s interesting to note that 85% of hospital beds nationwide are owned by non-profit institutions. The non-profit market share is 100% in the high cost New York City and Boston markets. I think this is an area that deserves a lot more attention that it’s gotten so far.
    Finally, regarding brand name drugs, the industry has lost many billions in sales just within the last several years due to patent expirations. I benefited personally by being able to switch from Zocor to Simvistatin and from Altace to Ramipril. In other therapeutic categories, Fosamax and Prozac are now available as generics. Believe it or not, the drug retailers and PBM’s actually make more gross profit dollars on a $20 generic than on a $100 brand name drug but the brand drug manufacturers take a significant sales and profit hit as they should.

  12. Barry;
    Speaking of QALY metrics for drugs, see the link below for such metrics on Plavix vs. aspirin.
    http://content.nejm.org/cgi/content/short/346/23/1800
    Now, I am just speaking theoretically and therefore no offense intended, but maybe if you had to pay for Plavix yourself you would be bringing this data to your physician’s attention. Therein lies another part of our problem.
    And, the patent on Plavix was supposed to expire in 2003, but was extended by the company simply separating the 2 molecules that comprised it and offering the one with the blood-thinning effect as “new”, thus extending the patent. We will see what they come up with in 2011.
    yes, pharma is only one of the issues driving cost. However, like curing different types of cancer, it looks like we are going to have to address each issue one at a time, solving them one by one.
    And I accidentally read Nate’s post about the 288K bill.
    Wonder of wonders, I agree about the hospital war! The additional irony is, did the patient really need the defibrillator(those are overused too)??!! Rhetorical question, of course.

  13. is that what the Russians where telling each other as millions where starved? As Pol Pot masacured millions did they hold hands comforted by knowing they served the larger self purpose?
    For humankind to succed and fullfill its potential we must each fulfill our personal potential. When millions of liberals don’t work and decide to live off others that creates a parasitic relationship that slows the growth of all. Intentially carrying a parasite doesn’t make you a nobel person it just makes you a less efficient person.
    American society carries millions of people who are perfectly capable of contributing to society but choose not to. We aren’t talking about the truly disabeled but those that insist on making poor decisions becuase the personal ramifications are minimal or positive, i.e. paying welfare moms more for each kid they had. Liberals wheren’t helping welfare moms by doing that they where enableing them to make more poor decisions. Creating a larger burned on society.
    Lets look at the history of progressive ideas, we’ll leave out non american cases so you don’t look so bad.
    Public Housing, it was progressives who thought rounding up the poor and locking them in high rises was morally rightous. Generations of minorities destroyed
    Public Education pushed by progressives leaves the majority of our poor uneducated and without a HS diploma
    Medicare created a 34 trillion dollar liability and didn’t provide the catostrophic care seniors needed.
    You get the point don’t you? As a progressive you really are closer to a disgusting tyrant who has directly murdered tens of thousands and is responsible for destroying millions of lives then a saint. If your proud to wear the label then bask in your destruction.
    A man that cared for himself never died waiting for a handout from his master. Far more then can be said about your progressive movement

  14. Mike, this must be the most eloquent, thoughtful, well written comment that I have seen in a long time.

  15. Nate, Some people send $100 to politicians while some industries send millions of dollars to politicians. Seems like insurance companies are looking after their interests, pretty much like I would be doing with my contribution. It’s not a fair fight, but we all do what we can.
    I posted my situation not because I was looking for insurance advice (although advice such as yours is useful, both as a practical suggestion and as an object lesson in how bad the situation really is) but because my situation seemed to exemplify at least 2 pathologies of the current system.
    But your crowing about “personal responsibility” is tiresome and suggests a limited moral vision. I participate in political action and campaigns for progressive ideas because my sense of self (my “personal responsibility” in your terms) extends beyond my self to include all the other selves running through the insurance maze.
    Self benefit in the narrowest sense is all that rats and insurance salesmen really trade in. Some of us however have a vision in which our self interest is intertwined with the collective interest.
    It’s the relationship between personal responsibility and social responsibility that you fail to grasp.
    “If I am not for myself, who will be for me? But if I am only for myself, who am I? And if not now, when?”
    (As for the “when” question, it had better including advancing implementation dates to 2010, or the Democrats will pay at the polls.)

  16. speaking of hospitals, have a 288K hospital bill in my hands for 7 days to put in a defliberator. Medicare payment 20K or so, cost basis says 15K or so. Group was with a major carrier who took a 5% prompt pay discount then tried to pass the bill to the employer.
    Before we fight the bio drug battle, which will be nasty, we need to win this hospital war.

  17. Bev MD,
    The good news about Plavix is that it is scheduled to lose its patent protection in 2011. Lipitor, Pfizer’s cholesterol lowering drug and the #1 drug in sales, goes off patent in 2012. With generic competition coming in 2-3 years, help (with costs) is clearly on the way. Unfortunately, I can’t say the same with respect to serious malpractice reform, sensible end of life care, robust price and quality transparency tools, widespread use of interoperable electronic medical records, reductions in regional practice pattern variations, serious efforts to mitigate fraud or cultural changes among either doctors or patients.
    I would single out hospitals for killing us financially when they’re not killing us with infections. On the drug front, ultra expensive specialty drugs, especially those that attempt to fight cancer, are likely to be the biggest contributors to cost growth within the drug space. This is an area that lends itself well to QALY metrics, but I don’t think this country will be ready to embrace that concept or approach anytime soon.

  18. The Plavix story is interesting. It’s a good drug although it essentially does the same thing as aspirin with fewer side effects but an order of magnitude greater price.
    However, its sales, already blockbuster in nature, I am sure exploded when studies found that in order to avoid the rare but fatal late thrombosis(clot) complication of coronary stents, patients must remain on Plavix pretty much indefinitely. Of course, way too many people were stented for years until studies accumulated showing that only certain subgroups benefited from it…….so now we have all these people on permanent Plavix, who shouldn’t have even had the need for it in the first place….. I am sure its manufacturer will fight like heck to keep it on patent, it’s supporting the company.
    Who said we don’t have a great medical system?

  19. Mike makes a good point. Access to affordable healthcare should not have rely on how good your group (over other groups) can negotiate prices, fine tune small print contracts, or finesse your way through the maze of healthcare intricacies – even though it might elevate the ego of your TPA.

  20. Barry we have another product we use for brands, it’s like reverse ebay with pharmacies from all over the country competing to fill the Rx. Usually at any given time someone has some extra Plavix sitting around they want to get rid of.
    No meaningful cost reduction will accure until people fill something else like you said. I like plan designs that have no deductible but co-insurance from first dollar on. Make the consumer contribute to every expense, throw in some information and alternatives and we might start making some progress.

  21. LOL, ya mike Keep telling yourself your above the maze. If that is what you need to hear as you sit in the corner and starve to death so be it. Some people take responsbility for themselves, others send $100 to politicians and hope for help.

  22. Nate – Those are indeed impressive savings on the four generics. I have no idea how much Express Scripts bills my employer for these net of my co-pay. As you probably know, the big Pharmacy Benefit Managers (PBM’s) including Medco Health Solutions, Express Scripts, and CVS/Caremark all claim to save employers money by driving up generic dispensing rates and by encouraging docs to agree to switch a brand to a generic or not checking the DAW box on the prescription form so the PBM can just provide the generic in the first place when filling mail prescriptions. We’re now approaching a 70% generic utilization rate nationally though they account for less than 20% of the dollars spent on drugs. As your research confirms in the Plavix example, nobody has any leverage with the big brand name drug manufacturers including Wal-Mart, the big drug retailers and the PBM’s. The drug companies’ attitude is if the docs prescribe it, you have to carry it and the price is the price. Drug retail and PBM profit margins on the sale of brand name drugs are extremely small. Almost all of their profitability is in the sale of generics.
    That all said, if I were a self-payer, I would call Wal-Mart, Target, Costco or Sam’s Club to seek the lowest price for generic drugs. Interestingly, one positive unintended consequence of the crazy donut hole in Medicare Part D is that once seniors enter the donut hole, they suddenly become much more price sensitive and more willing to accept generic alternatives to brand name drug prescriptions. There’s that difference between spending one’s own money vs. someone else’s again.
    The advantage the big box retailers have is that they have lots of other merchandise to sell once the customer is in their store. While drug retailers sell general merchandise as well, selling drugs is their core business (over two-thirds of sales) and, for PBM’s, it’s their only business.

  23. Why Nate, that’s a perfectly sane approach to coping with a perfectly insane system.
    Thanks for the suggestion on how to save a little money, but if I find a way to save $100 a month I think I’d rather send it to a politician working for a universal care system that will put people like you out of business, or at least stand up a strong and growing public option that will grab market share from the vultures.
    Would my investment bring do me any good personally? It’s a long shot, but at least it would give me the satisfaction of not having cooperated with the myopic obsession with small differences that you like to encourage. Ever seen rats running in a maze, obsessed with making the right approach to getting the cheese, but unable to understand that they are in a maze?
    As just another a rat in the maze your approach may make some sense in my situation, but for now, I’m looking down on the maze from above, watching all the rats following strategies like those that you recommend, and hoping that the Democrats will come to their senses and design an entirely new cage for us all, naturalistic and ecologically appropriate.
    Unless their reforms begin to bite in 2010, they are going to do very badly at the polls. I may yet have to follow your ratty advice for how to get through the maze but I’m hoping for something much better.
    Metaphorically speaking,
    Mike

  24. Mike,
    Can I make a suggestion? Your paying $1100 a month for a $1500 deductible. And your afraid to use it, I disagree with that fear but if you feel it then it is real. You don’t seem to have any problem acknowledging it so embrace it and take it into consideration when you purchase a plan. If your afraid to use it then admit it most likely wont be used and buy a $2500 or $5000 HSA. Not knowing your state these are guesses but going from $1500 to $2500 will probably save you $200-$300 a month. To $5000 will save you $450-$600. Take that premium savings and put it into your HSA. If something so bad happens you have no choice but to see a doctor you have the money saved to pay for it. If you continue to live in fear and don’t see the doctor after a few years you will have the entire deductible saved.
    The only way you lose is if 2-3 family members all need care in the same year, something that doesn’t sound likley from your post.
    Smarter consumerism will solve many problems.

  25. Barry and all curious consumers part 2
    1. Isosorbide Mononitrate – 30 mg — $36.97 per 90 pills. $10.00
    2. Plavix – 75 mg — $445.97 per 90 pills. $444.49
    3. Bisoprolol – 5 mg — $92.99 per 90 pills. $35.42
    4. Simvistatin – 40 mg — $75.97 per 90 pills. $23.69
    5. Ramipril – 10 mg — $175.97 per 90 pills. $19.20
    This says a lot about why healthcare is expensive. It took me a ton of time to talk Wal Mart into opening this up for my small clients, now that it is available it is taking even longer to convince them to sign the agreement. Huge Rx savings just sitting there and people can’t be bothered to take it. When people cry that health care is to expensive and business can’t afford it that is not entirely true, if it where they would jump at the chance to cut their generic cost 70%.

  26. Of course HB 3200 attempts to address these issues of usability and risk of using… I’m just describing the current pathology, not the brave new world we hope for.
    SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.
    A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors (as defined in section 2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent.
    and
    SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
    (a) In General- In this division, the term ‘essential benefits package’ means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that–
    (1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice;
    (2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c);
    …etc. etc. elsewhere.

  27. “What good does it do to force people to get insurance if they can’t afford the usage costs? ” said Karen.
    Hey, I can relate. Technically I’m insured, but in reality I’m afraid to pick up the phone and schedule a physical (been several years, I’m 51) because I’m 100% on hook for cost of visit, plus first $1500 of costs (and I don’t have $1500 at the moment), and if they find what my increasingly active imagination thinks they might ( maybe? who knows ? )find, then I fear for my own and my families “insured” status.
    I have to protect my and my family’s insurability, in case I have to switch insurers and I don’t want to generate a preexisting condition record if that becomes necessary.
    I’ve already had the experience of requesting that a physician not enter an observation (that might or might not have clinical significance) in his record… because I was in the process of switching to my current insurer and I didn’t want to risk my insured status. I understood what I was asking him to do, and so did he, but he didn’t enter it (to my knowledge), in part because it was a preliminary observation and easy to pretend he hadn’t seen it. I was able to purchase insurance. If he had not done as I asked and refrained, who knows?
    Now that I have insurance I don’t really know what level of “insurance security” I have. I know I pay an insurance company $1100 per month for me and my family, but dare I test that insurance by using it and thus risking losing it? I’ll bet lots of people are in my position.
    So I’m waiting…. maybe next month, maybe next year, when I get around to it. Now, is this smart behavior for me? I actually don’t know, because I’m calculating the utility function for my family of four’s overall well being… my children’s insured status, the potential ramifications of losing insurance, the probability of my death or disability as a bread winner.
    Should I attempt to use the insurance that I nominally have? If I’m wondering that, then you can bet lots of people are. And maybe that’s a good thing… after all we do want to constrain health care spending… but maybe it’s a terrible thing.
    So like Karen said… the use cost is key, but also the risk of utilization…. dare I touch the medical system, or should I save my contacts with the system for a moment of medical crisis, for my family, or for me?
    Regardless of my personal interests, I think it’s best for my family to avoid risking contact with the system for now.
    In days of old, you might approach a mighty King with a petition for relief. He might solve all your problems, but by calling attention to yourself you might also risk his anger. Dare you approach? Certainly no approach to the King could be considered without expending the $1500 deductible for new clothes and bribes to the officers of the court. Perhaps it would be better just not to go there. It would be a delicate decision and one that could change your life. Such is the fundamental situation of the nominally insured individual in relation to the health insurance industry.

  28. way to obvious. That is the fatal flaw of Medicare, it pays less then cost for services that both should be done and those that should not. The key is to pay a fair price for only work that should be done.
    That is the role of us parasites everyone wants to get rid of. Next time someone argues how cheap medicare administration is this is a perfect example of what you lose.

  29. For all who quit reading Nate, I want to suggest that he put his finger on it.
    “Another example from Harvord (sic) after the cut in the late 90s;
    “The demand inducement hypothesis predicts that physicians will respond to reductions in their income by increasing the volume of their services when the income effect is strong and negative.”
    “The results show that physicians whose incomes were reduced the most by Medicare fee cuts performed higher volumes”
    Conclusion: If we want to lower medical costs, then raise fees paid to providers and control the volume of services. Or is that too obvious?

  30. Barry and all curious consumers
    At least one of these I have on a pricing analysis I did for a current client;
    4. Simvistatin – 40 mg — $75.97 per 90 pills.
    My client was paying on Average .90 per pill. Wal Mart DTE price $0.26 Average savings over 70%
    When I get the pricing back on the others I’ll let you know.

  31. Just when I’d about given up on THCB contributing anything relevant to conversation about the current goings-on, Matt closes his eyes, swings from his heels like the Phillies’ Pedro Feliz, & makes it a game again.
    Even Nate chips in with among his best posts ever in defense of the pragmatic concepts underlying employer self-funding (posted by Nate at Nov 1, 2009 6:55:52 AM).
    And wonder of wonders, by so doing he puts himself in league with Matt’s eloquent Four Horsemen in favor of making things better in ways perhaps not so reliant on congressional sausagemaking.
    This thread gives me hope that one day even MD as Hell may make some sense.

  32. Why no insistence on meaningful tort reform to bring fairness to a system that is manhandling the medical profession and exposing the public to risk and expense of unnecessary defensive medicine? The Congressional Budget office has belatedly admitted that tort reform would save billions of health care dollars. Isn’t this a better source of funding than taxes? Pelosi’s absurd offer of incentives to states to study the issue, but caps on non-economic damages and addressing attorneys’ fees are prohibited. What is her notion of tort reform? Finally, no incentives for any state that has already enacted tort reform, like my state Ohio. Punish those states (and idividuals) who have performed well and reward those who haven’t. Exasperating for this physician. See http://www.MDWhistleblower.blogspot.com

  33. Sometimes nothing is better than something. Should out goal be to not make the delivery system any worse?
    It seems to me that it is time to look down the road at the implications of what is happening, what are we getting for our money other than more people enrolled in a system in need of fundamental change? And, more to the point what is this all really costing and who will pay? The short answer is nobody really knows and the people paying are those enrolled in Medicare, health care providers, and the 200 million Americans who already have health insurance (and yes our children).
    We were looking for health care reform and what we are getting is expansion of the existing system and health insurance reform that results in more not less cost.
    As we get down to the wire on health care reform, perhaps it’s time to step back and look at what is really happening. At the risk of being labeled a spoiler or naysayer I have summarized what I see as the end game within the legislation current under consideration..and it ain’t good.I was somewhat pleased to see that the WSJ in its editorial today came to the same conclusion that I have been espousing for the last several months. You may want to take a look. http://www.quinnscommentary.com
    Only one goal has been achieved in the proposed legislation and that is to expand coverage, but at great (and largely unknown) cost. Whether you agree with me or not, you should know what the implications are for all Americans.

  34. Good post, and a group that includes me as well. I just started reading this blog yesterday and I also agree with Bev MD, I stopped reading Nate’s posts (the people want tort reform).

  35. The problem is not of intellectual dispute, the problem is of end goal and the pragmatism….
    We do not want to be those TV pundits who if you hear, you may have to define the meaning of pundits.
    Healthcare debate is about the country, its security, its people, and american value system. We believe in capitalism, but healthcare is the least capitalistic. It is merely a business filled with lobbyed regulations to gauge the consumer. If it is about free market, then we have controlled even the very basic training of doctors and their numbers…
    We can go on. We just have to understand what we want to achieve.
    My view as articulated numerous times here and on my blog has been that having a healthy society is a basic infrastructure issues, just like we want good roads and stable electricity, and phone, and all that.
    So it is in national and personal interest to design a health system that develops a soild national foundation. Covering all does not create any healthcare cost; it simply brings accountabiity to all. We do need a way to reduce abuse but those who are sincere, they must be able to take care of themselves without emptying their pockets.
    rgds
    ravi
    blogs.biproinc.com/healthcare
    http://www.biproinc.com

  36. Matthew,
    You must be referring to the lefties and their intellectual debate. Now is the time for the right to turn up the heat in the intellectual debate. The case for reform as proposed is fading fast in the light of truth. Too expensive. Too intrusive. Too big. Too true.

  37. nk,
    In 2014 the patient will be at the keyboard and I will tell them what to do with it.

  38. “Barry would you mind sharing the 5 drugs and the cost for each for a 90 day supply?”
    Nate – Sure, I’d be happy to. First, under my employer’s plan with Express Scripts, my out of pocket cost for a 90 day supply of drugs ordered by mail is $20 for generics and $40 for brands which works out to $120 per quarter or $480 per year (actually 360 days) for my five drugs. That’s about 14% of what it would cost at drugstore.com prices if I had to self-pay. The list is as follows, all taken once per day:
    1. Isosorbide Mononitrate – 30 mg — $36.97 per 90 pills.
    2. Plavix – 75 mg — $445.97 per 90 pills.
    3. Bisoprolol – 5 mg — $92.99 per 90 pills.
    4. Simvistatin – 40 mg — $75.97 per 90 pills.
    5. Ramipril – 10 mg — $175.97 per 90 pills.
    In the case of Simvistatin (generic Zocor), Lipitor (Pfizer’s brand name drug) costs approximately 5 times as much for 40 mg, at least on drugstore.com. Let us know what you find.

  39. Wow. Is it normal that by the time I get done reading the comments I have forgotten what the original article was about? Sorry Matthew, but the people posting on this blog are the reason I am coming here regularly.
    Maggie – You are so smart and your posts are so spot on in many ways, but your obsession with defeating the Conservatives is exactly what has lead us to this point in this country. We are a country going through a divorce right now, Red vs. Blue, and very few citizens are taking the time to actually understand what this legislation will do or not do to us as a society. We are too busy trying to see if Obama supports it or if Rush hates it than to try understand it. We can point fingers all day long as to whose fault this, but that will get us nowhere productive.
    I disagree with you on one of your points and I believe we should “let good be the enemy of best” in this situation. I understand your frustration in your 30 year wait for this time in our country, but you know deep down that you did not wait 30 year for this half-baked bill.
    MD as Hell – If you think you are spending a lot of time at the keyboard now, wait till 2014….
    Anon – Rep Grayson should be ashamed of himself. There are hundreds of non-profit hospitals that are run by churches that are set up to specifically take care of uninsured patients in this country. Remember, he is a politician.
    The bottom line is that we have a perverse payment system, where docs get paid more the more they do regardless if it is right, and patients believe that more is better so they want more. Everyone is happy in this relationship. This is fundamental to the problems we are facing. Until this relationship is fixed, we are doomed.
    The way this system works is insane. Docs don’t know the real costs, patients don’t know the real costs and we are all living in a dream land of made up numbers. We cannot continue down this path. When we start asking “what is my cost” instead of “what is my share” we will be on the right path.
    If we add 37 million more to the insured list and don’t do anything to remove this insulation from true costs we will have failed on every level because no real reform will have been achieved.
    And if there is so much waste in the system as Orzag contends (and I agree with), then lets get rid of the waste. Everyone on this blog knows that the waste will not just simply go away. How can it when we don’t even know the real costs of our system?
    Just a reminder, in 1963 the CBO said the first year Medicare costs would be $200M+ the actual amount was $1B. Remember this when you so passionately defend your point of view. We are human and we get it wrong a lot. This is a $2.4 Trillion bet we are making. If we are going to do this, lets do it right.

  40. “I rechecked the price of my five heart related prescriptions (4 generics and 1 brand) on Drugstore.com. If I had to pay the cost myself, it would come to $827.87 for a 90 day supply of each or $3,311.48 per year.”
    Barry would you mind sharing the 5 drugs and the cost for each for a 90 day supply. We could give the THCB readers a lesson in consumerism, a number of them seem to need it.
    Have you checked Wal Marts new direct contracting? Their DTE program is saving 30%+ on generics. I set my clients up with another program where you post your Rx online and pharmacies bid for them, it also can cut Rx bills in half or more.

  41. “But here’s the good news: We can begin to eliminate waste even though the details aren’t in the reform legislation. And It’s Happening.”
    Palin warning about death panels is exageration and lies nothing in the bill creates death panels, but here without anything in the bill we magically cut waste and are already doing it. Seems a little controdictory to me. In light of the liverpool death panels, which also no law explicitly creates, I think seniors have every right to be afraid of Liberals talking of savings and saying don’t write it in the bill people will object there are other ways we can accomplish it, but oh don’t worry we wouldn’t do that with death panels, we promise.
    “Experience shows that when you lower fees for tests, the volume of tests levels off.”
    More BS Maggie, the truth is when unit reimbursement is cut volume increases. From 2003 after the 2002 cut;
    “Even when Medicare reduces the payment for each service, total Medicare spending for physician services can still rise if doctors perform more services, or more complex services for which the government pays more. That is what happened last year.”
    Another example from Harvord after the cut in the late 90s;
    “The demand inducement hypothesis predicts that physicians will respond to reductions in their income by increasing the volume of their services when the income effect is strong and negative.”
    “The results show that physicians whose incomes were reduced the most by Medicare fee cuts performed higher volumes”
    Even your vaunted MedPac in “Medicare payment to physicians” 11/17/05 says your full of it and have no idea what your talking about. Does anyone really belive the lies comming out of your computer?

  42. I am exploring sending a 1099 form to all my bad debt patients. If they won’t pay me, they can pay the IRS the tax due on their undeclared income.

  43. Considering the fact that Rule #1 is nothing more than moving money around, I assume that you are banking on the fact that the American public can be easily duped by bad politics.

  44. “The $10,000 cap on out of pocket spending even for affluent families (and a lower cap for poorer families) also eliminates medical bankruptcy. (If you owe only $10,000 a hospital and doctors will let you pay it off over time, because they know you can.) This is a huge change.”
    What a shock another post from maggie and more made up facts with no supporting evidence what so ever. If you ever bothered with facts Maggie you would know the DOJ found 50% of BKs had ZERO medical bills. Only 11% had medical debt in excess of $5000 and further still only 5% of BKs was medical debt equal to 50% or more of total unsecured debt. Huge deal for what 75,000 you have to be joking. You have been pushing this BS myth that out of pocket medical expenses are a major factor in BKs, it aint true, it aint even close to true. And it sure aint a big deal. You want to destory one of the few remaining utilization controls to possibly maybe save 75K people from BK. 150 million people won’t be able to afford insurance but for a year or two 75K won’t go into BK. Liberal Brillance at its best

  45. Roll Call reported that Rep. Alan Grayson (the republicans want you to die quickly Congressman) broke down in tears several times on the House floor on Wednesday afternoon as he read letters from people who said their loved-ones died because they were uninsured. Calling for Congress to finish its work of health care reform in America, Grayson concluded his remarks by saying, “for God’s sake, I look forward to a time when we have finally done our jobs.” I agree, this is not a time for cynicism. We can call for improvements in reform next year. Right now, let’s just get reform through Congress.

  46. Margait–
    Thanks.
    I really do do believe that, over the long term, what I have predicted will turn out to be true.
    I also think that being optimistic is the most contructive thing we can do–in terms of pushing legislators forward. And we can’t help conservatives undermine the credibility of the reform movement.
    I understand that many progressives had enormous expectations last November.
    But I think that, in many ways, Obama was oversold. Some of his supporters talked about him as a super-hero.
    No human being could live up to that. He took office at such a difficult time. Abramham Lincoln may be the last president who came to the White House facing such challenges . .
    Obama inherited a horrible situation. He’s not responsible for this. (We, the people, elected roughly 30 years of bad government. Bill Clinton could have been more effective but the Republicans managed to take over Congress , and then Clinton’s own lack of impulse conrol wiped him out. Jimmy Carter was a good man, but didn’t know how to play Cognress. He wasn’t a seasoned politician, )
    Now, I think the Obama adminstration gives us a shot at good government. Hardly perfect. But some very smart people in his administration, many with very good values.
    And it’s quite possible that legislators with more princpled values will be able to ride the administration’s coat-tails into Congress.
    Faith that this coutnry can change– positive thinking–helped elect Obama. I believe that we have to continue in that direction.
    This is not a time for cynicism. Next year, we can begin to call for improvments in reform.
    Right now, let’s just get reform through Congress.

  47. Maggie,
    It really doesn’t matter what we pay for specialists or expensive tests and studies. If they are not needed and not performed, they won’t cost a nickel.
    Control the patient’s care at the primary level though agreements and fair pay and suddenly health care isn’t so expensive.
    Health care historians looking back, will some day observe that the cost crisis began when we pressed down on provider fees. Like a rogue balloon, up popped unnecessary care and waste.

  48. Maggie,
    I do understand what you are saying. I do understand that we are changing the status quo in a very short time. I do understand that various agencies are expressing their various intentions to try and cut costs in the next three years and I do understand that fixing health care is a journey, and you have to take a first step at some point and it doesn’t matter much if it’s a big step or a small step, as long as inertia has been overcome.
    I guess my problem is that I had enormous expectations last November and as usual reality got in the way.
    I hope you are right on this one, Maggie and I sure hope that my general feeling of disappointment is misplaced. Only time will tell. I will be rooting for your predictions to come true.

  49. No primary care doctor mid-career is only making $150K. I have PA’s that are making $90K plus benefits.
    Oncology is the specialty with built-in research. Patients are put on protocols to see if treatment works or not. This is all funded by Uncle Sugar. Patients want hope, not statistics.
    Medicaid fees raised to Medicare rates for primary care is a joke. I still wouldn’t take Medicaid. Why don’t you raise TriCare rates while you are at it. No one wants that either.
    When a procedure is too lucrative (like government-run healthcare?) the incentive is too great. Well, you are all jumping on this one, aren’t you. Who gets the brass ring?

  50. 27 years of bad government starting with DRG’s. COBRA/EMTALA has brought you the overcrowded ER. HIPAA has just brought stupidity. Documentation requirements have brought you less productivity. Bring on EHR! The more time I spend at a keyboaRD, THE LONGER YOU WAIT IN THE er.

  51. pbnesbitt–
    First, thanks for reading my long comment.
    Secondly, it’s very important not to confuse Medicaid and Medicare fees.
    The people who are suing in Florida (rightly, I might add) couldn’t find a doctor who would take Medicaid.
    Medicaid, the government program for the poor, pays an average of 30% less than Medicare– the government program for seniors– for exactly the same services.
    This is becuase when Medicare/Medicaid was passed, Southern Congressmen made it clear to LBJ that they would not vote for the legislation if doctors and hospitals that cared for poor patients (often black) were paid as much as providers who cared for seniors (mainly white- in 1965 most blacks didn’t live that long.)
    The reform legislation now on the table. raises Medicaid fees to Medicare levels for primary care. This is a Major step forward.
    Not enough –but Huge progress in just 10 months.
    Secondly, Medicare is cutting fees for specialists performing certain procedures where we know that there is a huge amount of overtreatment.
    Medical evidence shows that more than half of all patients who undergo angioplastiets and bypasses derive no benefit–and are exposed to unncessary risk.
    This is why they are cutting cardiologists’ fees. Experience shows that when you cut fees, the volume of procedures drops. When you make a procedure too lucrative, you are creating incentives to “do more”
    Similarly, too many oncologists overtreat patients. As one oncologist (formerly a memeber of the American Board of ONcologists) wrote on my blog: “Oncologists are making a stack of money providing chemo for patients who won’t be helped.)
    These are not doctors who are struggling to make ends meet. Typically, they are earning $400,000 -$600,000 a year, often far, far more. ($1 million, $2 million . .)
    And Medicare is using part of the money to hike fees for primary care docs– who typically make around $150,000 a year, mid-career.
    The committee that has been updating Medicare fees for the last 15 plus years is comprised mainly of specialists.. They meet behind closed doors. No minutes of their meetings are available. And they almost always raise fees for procedures done by specialists–even when new technology makes procedures simpler.
    This is why some of our specialists are overpaid.

  52. Bev MD – I rechecked the price of my five heart related prescriptions (4 generics and 1 brand) on Drugstore.com. If I had to pay the cost myself, it would come to $827.87 for a 90 day supply of each or $3,311.48 per year. 54% of the total cost is for the brand name drug, Plavix, which goes off patent in another couple of years.
    Separately, it defies common sense that you or anyone else should have to pay the full list price for services within the deductible. Nate says his clients all pay the insurer’s negotiated rate which is the way it should be, in my opinion. Before my own employer eliminated its in network deductible and just went to co-insurance up to an out of pocket maximum, we always paid the negotiated rate for the within deductible services. I would look for another carrier if I were you.
    Margalit – Regarding high deductible health plans, it shouldn’t be hard to establish income and/or liquid asset criteria that would qualify individuals to get a waiver from minimum coverage regulations so they can buy a high deductible health insurance plan instead. The process could be repeated each year if necessary. Sure, financial circumstances can change materially and on short notice, but we can’t protect people from every conceivable risk. Moreover, I just don’t buy the less money in the pool argument. Insurers will all tell you that their medical cost ratio on high deductible plans is the same as it is on their more comprehensive products. Similarly, the medical cost ratio for Medicare Advantage members with above average risk scores is quite similar to the ratio for members with below average and average scores because the insurers receive risk adjusted premium payments from CMS.

  53. Margait–
    I often agree with your comments on THCB (even though I usually don’t have time to comment), so I want to reply to you and try to explain what I’m saying one more time.
    After just 10 months we have a bill that provides affordable quality care for low-income Americans and almost all of the statistical middle-class.
    They get subsidies. And the bills are calling for
    comprehensive care–going beyond what employers now provide to include dental and eye care for kids. I don’t think there should be high-deductible plans– but there probably will be.
    The public plan, however, will not be high-deductible. It will be modeled on Medicare. So in the end, no one will be forced to choose a high-deductible plan. ( Ultimately, everyone will have a chance to join the Exchange and pick the public plan.)
    As I said in my last comment above, we stil have to make care affordable for the upper middle-class and the upper-class.
    The adminsitration and the legislation have explained that this can be done by eliminating unncesasry tests, procedures, and refusing to overpay for many services and products.
    They have 3 years to do this. It can be done. The Medicare Payment ADvisory Commission has been issuing 250 page reports, twice a year, that provide a blueprint for how to do it. White House budget director Peter Orszag has read those reprots– as has his health care advisor, Zeke Emanuel.
    Medicare has already started to make the cuts (see my comment) Private insurers have already said that they will follow Medicare’s cuts.
    Okay, so we make insurance affordable for the upper-middle-class. (By the way, that doesn’t mean free. In Europe the average middle-class/upper-middle-class household spends 10% of it income on health care before getting help from the government. That’s the price you have to pay if you want to live in a society where everyone has access to good care, and no one goes bankrupt trying to pay for it.)
    Will this legisaltion still leave some people. uninsured? Yes.
    First, there will be people who refuse to buy insurance and instead pay the penalty. I think the penalities should be much stiffer–and I’m quite certain they will be raised. Peter Orszag can add and subtract. He will understand that, without stiffer penalities, reform will never work. We need young, healthy people in the pool. Obama is going to have to use all of his consierable charisma to sell this.
    Still, many immigrants will be left uncovered. I dont’ know what to do about this. The majority of Americans don’t want to include immigrants– even legal immigrants. Even Massachusetts-probably the second most liberal state in the nation (after Minnesota)– is willing to throw legal immigrants under the bus.
    This is racism, pure and simple.
    But to be fair, on this point legislators are representing the majority of their constituents. This is an ugly fact, but true.
    Keep in mind that only 48% of white Americans voted for Obama. And white Americans like Obama a lot more than they like immigrants.
    My best hope is that the Obama administration puts enough money into public health measures (which it is doing) to help immigrants.
    And perhaps, if we get enough new blood in Congress in the next four years, we’ll have a Congress willing to include immigrants in healthcare reform.

  54. Maggie,
    “That brings us to #2. We need to reduce the cost of care. This means eliminating waste–and shifting the emphasis to primary care.”
    You are right and this is the discussion that counts. Without eliminating waste, we cannot solve the health care conundrum.
    Also, you say, “Here, what I don’t understand is why the Four Horseman ignore the fact that we can do this (and in fact ARE doing this) without spelling out how to do it in the legislation.
    Trying to be explicit about elmiinating waste wihin the legislation would be dangerous for two reasons. First, we don’t want politicians making decisions about where to cut medical spending. (They’re not physicians; they’re not medical reserachers.)”
    Agreed, but we need not postulate politicians as the promulgators of medical cost savings. We already put this responsibility in the hands of insurers. Why not put it into the hands of the medical community?
    You address cutting medical fees, “Secondly, if the legislation began to talk about cutting fees, there would be a Huge protest, not just from the lobbyists, but from the American public.
    Americans do not want their doctors’ fees cut. They believe those who say that if we cut specialists’ fees, cardiologists will retire and they won’t be able to get a bypass when they want one (whether or not they need one) The public doesn’t want to hear that we’re doing too many MRIs.”
    You are correct again. Why should we expect doctors to cooperate when we keep cutting fees. There is a class action lawsuit in Florida against Medicaid because the patient’s family couldn’t find a physician who would treat the patient for the ridiculously low medical fees.
    And then you comment, “But here’s the good news: We can begin to eliminate waste even though the details aren’t in the reform legislation. And It’s Happening.
    From Friday’s Wall Street Journal: “U.S. federal health regulators on Friday announced new rules that will result in trimmed payments for doctors who use expensive medical-imaging machines to screen patients for diseases such as cancer and heart problems.
    The rules will cut by up to 38% the amount doctors will get when they use disease-screening equipment for procedures such as MRIs and CT scans. The rule applies to the roughly one million doctors who are paid under the Medicare Physician Fee Schedule, a program run by the Center for Medicare and Medicaid Services, or CMS.”
    So the answer is to cut the fees, right? Well, that’s really worked in the past, hasn’t it?
    Maggie, have coercive measures ever really worked? Why not consider exactly the opposite. Let’s pay providers fairly and promptly and extract from them a commitment to not treat inappropriately with unnecessary tests, studies, and consultations.
    While I’m not a physician, I have absolute confidence that, in the main, they will cooperate if we treat them with respect, allow them to practice medicine the way they were taught in medical school, and pay them fairly for their work. Most will honor their word if they commit to appropriate care. We can always build the necessary controls to oversee the system and catch those slip sliding away.
    I would love to see state Medicare programs adopt this approach since like Florida, they need help. In fact, it might help Florida solve their Medicare/Medicaid problems.

  55. Maggie,
    The principles as stated on the campaign trail and even thereafter were affordable, quality health care for all Americans. Unless you are saying that the bill under consideration provides that, then we compromised on principles. Whether the reason is to appease unions, or doctors, or insurers or pharma or whatever, is irrelevant.
    Your argument in a nutshell is that this is the best that could be passed under the circumstances and we live to fight another day from much improved positions.
    I take issue with the necessity to have such circumstances in the first place and I am not at all sure that the positions are much improved.
    As to lobbying, no, there is no traceable quid pro quo. Lobbying is not a buy/sell discrete transaction where you can show returns for each dollar. Lobbying is more like a hedge fund. You throw money all over the place, hoping that in total, you will come up ahead. It works.
    The people spending money on lobbying are directly responsible for P&L to their share holders, even if they are not spending their own money. CEOs usually don’t spend their own money. Every dollar spent on lobbying is one dollar less in immediate profit for the share holders. If lobbying returned no overall benefit, it would stop.
    Does some of the lobbying money go to folks that cannot be corrupted, like Senator Rockefeller? It sure does. I’m sure there are theorems and “best practices” in the art of lobbying that require that all powers need to be contributed to, even if it’s only to prevent their wrath.

  56. Margait–
    Exactly where in the legislation are we compromising on basic principles???
    Also,on the other thread you stated that, as a businessperson, you know that lobbyists would not be making huge contributions unless they are getting something in return.
    Here you forget that lobbyists are spending someone else’s money (ultimately shareholders’ money.) That is very, very different from a business owner spending his own money.
    Secondly, as I mentioned in the long post above, lobbyists make the biggest contributions not only to people with power, but also to people who they fear will hurt them. (Often, this means very principled politicians.)
    Look at contributions to members of the Senate Finance committee. Which Democrats got the largest contributions from health care lobbyists and insurance lobbyists?
    Max Baucus came first. This makes sense. As chariman he has power. And Baucus is known for compromising with conservatives.
    But #2 was Jay Rockefeller. He received significantly more in contributions from the lobbyists than any one else.
    What did Rockefeller give the lobbyists in return? A poke in the eye.
    He, more than anyone, insisted on the public insurance option. He wouldn’t compromise with Olympia Snowe and settle for puny public plans created by the states. He was right to agree that, after a year, states could opt out. This was not much of a concession. (As others have pointed out, it would be very difficult for politicians to explain to voters why they weren’t going to be given the choice of a public plan.)
    Jay Rockefeller represents a very poor state, and is a defender of the poor. I don’t see him as a corrupt politician. He is not someone who compromises on principles.
    Yet, he got more money than anyone except Baucus.
    This tells us that the amount that lobbyists donate to a politician does not tell you that he offered something big in return.

  57. Robin, I’m afraid I have to disagree.
    There is no parallel between the 1776 Continental Congress and the 2009 Congress. The purpose of the Committee in 1776 was to draft a Declaration of Independence of the American colonies from the King of England. What Thomas Jefferson included in his first draft was an accusation that the King promoted the trade of slaves, along with other highly emotional accusations. This was likely to have been intended for foreign consumption, since several Congress members wanted to secure foreign aid before declaring independence.
    Congress removed most of the emotional stuff and I have not seen anywhere documentation that there was a terrible debate regarding these edits. The equality of all men, by the way, was a jab at the King, not an implication that slaves are equal.
    Slavery was widely accepted at the time and Thomas Jefferson himself not only owned and traded slaves, but also published writings indicating that he by no means regarded the black slaves as equal to the white man. I believe he was opposed to slavery because of immoral effects it was having on white folks. He really thought that the Black people should be removed from America. He published works to that extent later on.
    Emancipation was never part of the contemplated solution in 1776. They did not settle on a compromise in 1776. They went all the way out and took an enormous risk because they believed in the basic principles.
    In 2009 we are casually compromising on all principles.

  58. Matthew–
    Thank you. I agree with virtually everything you say. (And Robin, thanks for the support. It’s lonely out here.)
    Matthew – I also suspect that the Four Horsemen and I agree in many ways. (Though I don’t agree with Bob L. that we needed a bi-partisan bill.) But I hope we all agree on the Dartmouth reserach.
    Thanks for pointing out the progress we’ve made on #1.
    Under the legislation, working class households and most of the statistical middle-class now have access to affordable care.
    This is progress. The $10,000 cap on out of pocket spending even for affluent families (and a lower cap for poorer families) also eliminates medical bankruptcy. (If you owe only $10,000 a hospital and doctors will let you pay it off over time, because they know you can.) This is a huge change.
    But we still have to make healthcare affordable for the upper-edge of the middle class and the upper-middle-class.
    That brings us to #2. We need to reduce the cost of care. This means eliminating waste–and shifting the emphasis to primary care.
    Here, what I don’t understand is why the Four Horseman ignore the fact that we can do this (and in fact ARE doing this) without spelling out how to do it in the legislation.
    Trying to be explicit about elmiinating waste wihin the legislation would be dangerous for two reasons. First, we don’t want politicians making decisions about where to cut medical spending. (They’re not physicians; they’re not medical reserachers.)
    Secondly, if the legislation began to talk about cutting fees, there would be a Huge protest, not just from the lobbyists, but from the American public.
    Americans do not want their doctors’ fees cut. They believe those who say that if we cut specialists’ fees, cardiologists will retire and they won’t be able to get a bypass when they want one (whether or not they need one) The public doesn’t want to hear that we’re doing too many MRIs.
    But here’s the good news: We can begin to eliminate waste even though the details aren’t in the reform legislation. And It’s Happening.
    From Friday’s Wall Street Journal: “U.S. federal health regulators on Friday announced new rules that will result in trimmed payments for doctors who use expensive medical-imaging machines to screen patients for diseases such as cancer and heart problems.
    The rules will cut by up to 38% the amount doctors will get when they use disease-screening equipment for procedures such as MRIs and CT scans. The rule applies to the roughly one million doctors who are paid under the Medicare Physician Fee Schedule, a program run by the Center for Medicare and Medicaid Services, or CMS.”
    Earlier WSJ articles explained that private insurers plan to follow these cuts. (Private insurers already follow Medicare’s fee schedule, just adding a %.)
    Earlier WSJ stories explain that private insurers have been chafing at the bit to cut fees for diagnostic testing. They have told MedPAC that if it took the lead, they would follow. The private insurers just wanted political cover.
    Experience shows that when you lower fees for tests, the volume of tests levels off. And of course we’ll save by paying up to 38% less for the tests that are done.
    The good news for patients is that they will no longer be exposed to what Dartmouth has called an “epidemic of diagnosis”, detecting “pseudo-diseases” as a result of too much testing. They also won’t be exposed to the excess radiation that comes with too many CT scans (volume has doubled in seven years.)
    Medicare is also cutting fees for tests done by doctors who bought or leased the equipment. When dcotors “self-refer” for tests, they recommend twice as many.
    In addition, yesterday Bloomberg reported that, next year, Medicare is going to cut cardiologists fees by 6% percent while raising fees for primary care by 4%.
    This is the Beginning of a Series of planned increaes for primary care docs. Between now and 2013 we’ll probably see two more increases. (Read MedPAC’s recoommendations.)
    Add them to the 5% to 10% increase in the legislation (planned for 2013) -plus the bonsues in the legislation- compound these hikes, and we’re moving toward 15% -25% increases. Plus foregiveness of loans and scholarships for med students who choose primary care. Plus pay hikes for nursing shcool teacheres, and nurse practioners, which means more nurse practioners to help family docs deliver care.
    Finally, as we give bonsues to docs who join accountable care organizations (or mutli-specialty groups that co-ordinate care with hospitals) working conditions for primary care docs will improve. The family practioners I talk to are just as concerned about working conditions as they are about money.
    Over a four-year period, Medicare is also cutting reimbursements to oncologists. Bloomberg explains: “The administration argued that the lower reimbursements for specialists would make more dollars available for lower-paid non-specialists who can focus on preventing expensive, chronic illnesses. That would tame the growth in medical costs, one goal of President Barack Obama’s effort to remake the U.S. system of care. Under yesterday’s plan, family doctors and nurse practitioners would get half the proposed increases.”
    Isn’t this what the Four Horsemen want?
    The beauty of this is that Congress is not involved in deciding and drafting these proposals. It only has 60 days to oppose Medicare’s decision–or let it automaticallly go into effect Jan 1.
    This is very similar to what Jay Rockefeller and Obama have proposed in terms of letting a panel like MedPAC oversee Medicare spending–giving Congress only 60 days to say yes or no to Medicare’s proposal. (This is how they handled military base closings– it really helped
    keep Congress and lobbyists out of the process.)
    I’m guessing that we’ll see that independent panel begin to oversee Medicare spending sometime next year. –Again, it doesn’t have to be in the reform legislation.
    Finally, as noted, private- sector insurers will follow Medicare’s lead in virtually all of these cuts– and increases. They would love to lower their costs, and they realize they’re having a hard time finding primary care docs for their networks.
    Medicare reform will pave the way for healthcare reform. For the last 8 years, Bush wouldn’t let Medicare implement MedPAC’s suggestions. (Former CMS director McClellan has talked about this.) Now, Medicare’s hands are no longer tied. Over the next three years, Medicare will be reining in spending (it has to), private insurers will follow suit, and much care will become more affordable.
    When the public option “negotiates” fees with providers it will be negotiating in a context where cardiologists are no longer paid what they were paid last year.
    Meanwhile, Medicare will also be using financial sticks and carrots to persuade hospitals to become more efficient. For instance, it has already announced it is not paying for an excessive number of preventable readmissions.
    This is how we bring premiums down so that care is affordable for the upper-middle class.
    Premiums for the public option will be significantly lower than premiums for comprehensive private plans.
    I know Douglas Elmendorf says that’s not true. I’m writing about this today. (Did you guys know that Elmendorf first tasted power in DC when he helped kill
    Clinton’s health care initiative, saying it was too expensive? )
    Matthew, I’m hopeful we won’t have to raise subsidies above 400%– and I don’t think we should subsidize the upper-middle class. (Otherwise, we’ll wind up taxing the same people we’re subsidizing) Instead, we need to bring down the cost of care, per capita or per episode.
    I suspect that Medicare will also begin negotiating for discounts on drugs–even if that provision doesn’t survive in this legislation.
    Pharma now takes about 16% of the dollars we spendon healthcare (10%-11% drugs bought retail in drugs stories, plus drugs administred in hostpials and docs’ offices, plus the devices Pharma also sells.) And Pharma is enjoying 16% profit margins.
    Much money to be saved there.
    Matthew– you ask why we’re waiting until 2013 to roll out care? Obama has always said he hoped to do this at the end of his first term.
    Gawande says it’s the only way to do it. (See the New Yorker article that preceded the June 1 article) Gawande is a wise man.
    Don Berwick points out we’re trying to “turn the biggest ship ever built.”
    It’s going to be difficult. There is the real danger of a public backlash. (There is much that the public will not like about reform. There will be a movement to repeal reform, led by conservatives.)
    You worry about the lobbyists. While I would love to see campaign finance reform, I don’t see that happening this year. (A huge problem is that the media– particularly TV — is completely dependent on that campaign/ad money. It’s a huge chunk of their revenue.)
    In any case, while the lobbyists are a problem, conservatives are a bigger problem. They have a huge amount of money (look at funding for their think tanks–and where it is coming from.)
    They can buy the media (FOX). They can (and have) made in roads into other parts of the media. (Check out WAPO’s editorial page.)
    Their agenda is not just to create a backlash against reform. They want to “break Obama.”
    If they succeed–and re-take Washigton- . . .we can forget about health care reform–and many other things.
    The conservatives believe in telling BIG LIES. (The strategy that Hitler explained: if the lie is big enough, people will think — no one would say THAT if it wasn’t true . . )
    So they say “Unplug Grandma.” They even get Grassley to say it.
    So reform has to be phased in–there can’t be any big surprises, or any big disasters (as there were when we opened up Medicare Part D. Patients couldn’t get prescriptions. Gawande points out that some died. )
    . We need three years to hammer out things like nation-wide regulation of insurers.(This is extremely important and will be very complicated. We need to study how other countries do it.)
    We need to raise penalties for those who choose not to buy insurance–without setting off a huge protest among younger Americans.) We need to figure out how the Exchange will work. We need to figure out how to adjust for risk.
    Most importantly, we need to begin squeezing the waste out of the system– reducing spending and lifting the quality of care–with Medicare leading the way.
    Mass. made the huge mistake of trying to roll out care without reducing waste. If we try to do that nationwide, it would create such a mess that I do think the legislaiton would be repealed. We can’t promise what we’re not ready to deliver.
    Orszag understands that much of the funding can be found within the system.
    The legislation allows Medicare to do this (without spelling out where the cuts will come and how dollars will be re-distributed to primary care.)
    The public option can help reduce costs when negotiating with providers–and it will have real clout. The first year, up to 25% of the population will be able to enter the Exchange, and pick the public option, if they choose.
    I know, you’ve heard 10%. But do the math: the uninsured (16% of the population, minus immigrants) and those who now buy their own insurance in the private market (another 10% of the population) will be eligible for the Exchange– which means they can choose the public option. Say that, two-thirds of the uninsured are U.S. citizens–, we’re talking about 20% of the population Add everyone who owns or works for a small business. In the second year, that means all businesses with up to 30 employees– that’s a huge number of people.
    At that point, roughly 25% of the population can choose the public option if they wish. NO ONE (including CBO) has a clue as to how manhy will pick it .
    And Matthew, I very much doubt that any states will opt out. Maybe one or two. But how do you tell the citizens of our state that they can’t have access to the public option???
    In the end, I too would like to see a bigger, better bill right now. But I’ve been waiting for this since the early 1970s. I can wait three more years–especially if we’re expanding Medicaid and SCHIP– taking care of the most vulnerable Americans first.
    I’m happy to see the glass at least half full. And I don’t want to hand the conservatives ammunition by complaining about how corrupt the Democrats are. For one, they’re not all corrupt. Lobbyists always make huge contributions when they see legislation coming their way. Health care lobbyisits made huge contributions to anyone who has some power. It doesn’t mean there was a quid pro quo.
    Jay Rockefeller got more from health care lobbyists and insurance lobbyists than anyone else on Senate Finance except Max Baucus.
    Can you tell me what Jay Rockefeller gave them in return? What he gave them was the publcic option–and he insisted that it had to be federal. It couldn’t be Olympia Snowe’s trigger, that would let states “opt in.”
    Secondly, they’re the only Congress we have right now.
    Obama got as much as he could out of them. And
    this legislation is just the beginning.
    Moreover, Obama hasn’t yet appointed a new head of CMS. I don’t think the White House wanted to go through that confirmation hearing while passing this legislation. But I’m convinced that the new director of CMS will be tough– as tough as the new deputy FDA commissioner who will be overseeing drugs and devices (and who doesn’t have to be confirmed.) Putting someone in charge of drugs and devices who didn’t have to be confirmed was a brilliant move. The industry was very upset.

  59. Maggie is 1 formidable woman, going toe to toe with 4 Horsemen as Matt puts it. In an ideal world, I would agree with the 4 gentlemen, but given this is Washington, politics, and 1/6th of the economy we are talking about, Maggie is right — the ideal has to make (at least some) room for the real.
    Over the summer I wrote a post on my Disruptive Women in Health Care blog in which I compared the parallels between the 1776 and 2009 Congresses. Here’s a little bit of what I wrote:
    In July 1776, Congress was working on the Declaration of Independence. A rather controversial undertaking with far reaching implications. In July 2009, Congress was tackling another controversial undertaking with far reaching implications. I am speaking of course about health reform.
    The parallels, and lessons learned, are striking.
    But perhaps the most important parallel was the challenge of one overwhelming lightning rod of an issue. In 1776, it was slavery—Jefferson, Adams and Franklin wanted to include emancipation along with Independence. Now, I want to be clear that I am by no means equating slavery with the current public option in health reform. Rather, I am pointing out the parallel of how one controversial issue has (had) the power to (almost) derail an act of Congress.
    In 1776, after much back and forth and heated debate over the issue of slavery—and whether to include it in the Declaration of Independence—the entire South walked out as a result of keeping emancipation in the declaration. (Warning to current Congress: Think Blue Dogs). In the end, it was Ben Franklin who ultimately persuaded John Adams and Thomas Jefferson that without independence there could be no emancipation. One step at a time.
    To reach their ultimate goal, Members of Congress in 1776 realized they would have to compromise. In the end, nearly one-quarter of the original Declaration is stripped out of the document, primarily the passage concerning slavery. Morally reprehensible.
    Back to the present. The health reform bill that ultimately passes will never be finished and will surely keep lobbyists and others busy with corrections, amendments, and improvements for many years, and politicians, to come.
    But we need to start somewhere. Back to the filtered cigarettes: Not all smokers quit cold turkey.
    In an odd way, this messy political process may just be the ultimate in user-generated health care.

  60. Maggie is 1 formidable woman, going toe to toe with 4 Horsemen as Matt puts it. In an ideal world, I would agree with the 4 gentlemen, but given this is Washington, politics, and 1/6th of the economy we are talking about, Maggie is right — the ideal has to make (at least some) room for the real.
    Over the summer I wrote a post on my Disruptive Women in Health Care blog in which I compared the parallels between the 1776 and 2009 Congresses. Here’s a little bit of what I wrote:
    In July 1776, Congress was working on the Declaration of Independence. A rather controversial undertaking with far reaching implications. In July 2009, Congress was tackling another controversial undertaking with far reaching implications. I am speaking of course about health reform.
    The parallels, and lessons learned, are striking.
    But perhaps the most important parallel was the challenge of one overwhelming lightning rod of an issue. In 1776, it was slavery—Jefferson, Adams and Franklin wanted to include emancipation along with Independence. Now, I want to be clear that I am by no means equating slavery with the current public option in health reform. Rather, I am pointing out the parallel of how one controversial issue has (had) the power to (almost) derail an act of Congress.
    In 1776, after much back and forth and heated debate over the issue of slavery—and whether to include it in the Declaration of Independence—the entire South walked out as a result of keeping emancipation in the declaration. (Warning to current Congress: Think Blue Dogs). In the end, it was Ben Franklin who ultimately persuaded John Adams and Thomas Jefferson that without independence there could be no emancipation. One step at a time.
    To reach their ultimate goal, Members of Congress in 1776 realized they would have to compromise. In the end, nearly one-quarter of the original Declaration is stripped out of the document, primarily the passage concerning slavery. Morally reprehensible.
    Back to the present. The health reform bill that ultimately passes will never be finished and will surely keep lobbyists and others busy with corrections, amendments, and improvements for many years, and politicians, to come.
    But we need to start somewhere. Back to the filtered cigarettes: Not all smokers quit cold turkey.
    In an odd way, this messy political process may just be the ultimate in user-generated health care.

  61. bev MD why are you not getting the PPO discount? As of 1/1 I have over 150 clients on high deductible plans and every single one gets the benefit of the carriers HD. What carrier/product did you go with?
    In regards to your bad bill is better then no bill I would ask you look back to 1965. At the time 87% of seniors paid 100% of their remaining lifetime healthcare cost with no problem. 13% of the senior population needed assistance. At the time the public wanted to help the 13% and offer catostrophic coverage for the 87% of seniors.
    We got a terrible bill that didn’t even try to address the catostrophic need, instead it did the exact opposite and cut off coverage in catostrophic situtions. Now less then .0001% of seniors pay their own medical expenses, 19% of seniors are on Medicaid, and we are 34 trillion underfunded.
    A bad bill turned what was a very solvable problem into a national crisis. 40 years of attempts to address the cost issue have all failed.
    This was also repeated with TennCare and numberous other government health plans. I can’t think of even one instance where financial pressure moved things in the right direction.
    Fix cost access will solve itself.

  62. “While I recognize a need to define minimum acceptable coverage, I don’t think it is appropriate to preclude insurers from offering high deductible policies to people who want them and can afford to assume the risks.”
    Barry, I think this will raise premiums for those that cannot afford to assume the risk. Besides, unless you come up with some sort of validation that they indeed can assume the risk, many will be tempted (or forced) to opt for the lower premiums and take a chance that disaster will not strike. Not to mentioned that the ability to assume risk can drastically change in a day or two.

  63. Barry;
    One more thought – if you were a heart transplant patient, yes the costs would be high. I didn’t think of that. And I’m straying dangerously into privacy territory here, so no reply necessary. I was just trying to generalize about drug costs; sorry.

  64. Barry;
    Yes, of course you are right this is not a good bill (and so is Nate if he said that). However, like Massachusetts, having passed coverage for almost everyone (which I disagreed with; they should have addressed costs FIRST), the “govmint” will be forced to address costs when this bill causes costs to really spiral out of control – e.g., causes a crisis. (remember Matthew saying it would take a crisis?)
    It is for this reason that I cynically, but honestly, think a bad bill is better than no bill. It will force change in the right direction – eventually, after a lot of angst.
    And BTW, in my opinion your heart drugs should not be costing anywhere near 3-4K per year. (Caveat: this is nowhere near my specialty.) Now for some of the new biologics against cancer, maybe. But there just isn’t that much of a breakthrough in cardiac drugs for maintenance drugs to be costing so much. Statins – going off patent, or should be, if big pharma were prevented from preventing that. Antihypertensives – there are many that work, none should cost such an outrageous amount. Anti-congestive failure drugs – ditto. So your example is part of why costs are so high.
    And ps, I DO have the 10K deductible – and DO NOT get to pay the negotiated discount. It’s a real eye-opener, let me tell you.

  65. I’m sorry but I don’t see how the current bill actually offers much in the way of goal #1. It may be true that some yet to be clarified percentage of poor people will have insurance but that in no way equates to a significantly greater proportion of the citizenry having access to treatment when needed without destablizing family finances.
    Remember 78% of bankrupts last year had insurance and yet 62% of then listed medical debt as a precipitating factor in their insolvencies. What good does it do to force people to get insurance if they can’t afford the usage costs?
    By framing the problem as “the uninsured”, legislators and analysts ensured that the “solution” would involve more of the same dysfunctional model that got us where we are.
    Insurance companies are not “the” problem with US health care. Doctors and hospitals are not “the” problem” Demanding patients pursing unhealthy lifestyles are not “the” problem.
    *The* problem we have is that we insist on trying to tweak an unsustainable model into something that works. It’s a delusion and this latest effort will have no more effect than the past 30+ years of tweaks.

  66. Matt: Nice try, my friend. However, I think your position on this is like accepting filtered cigarettes as “progress” because smoking them is somehow “better” than smoking the unfiltered brand. And, because we can’t get the cigarette companies to admit that nicotine is a terrible addiction, and that smoking cigarettes kills people, we should accept this half-measure as better than none at all. But a lie is still a lie, even if sweetened a bit.
    As Brian Klepper stated in his response to one of Maggie’s coments: “Back to the core arguments of our article, the current proposals do little if anything to correct the 3 most important structural underpinnings of the current crisis: fee-for-service reimbursement, transparency, and specialist-dominated care. The proposals all but ignore everything that progressive health care practitioners have learned over the last 25 years about how to best manage the care process. The most straightforward and logical reasons for the disconnect between what many of us interested in reform for many years and the current process is that change in the public interest would drive significant dollars away from the special interest.”
    What I think this argument about is the adequacy of the political process to address the significant, dangerous, and mounting problems that face the public and the republic. Brian, Alain, Robert, and I represent those who think the political process is inadequate and has become fundamentallly flawed, and therefore unable to reach a successful solution. Maggie and her crowd are pleased with the current political processes, accepting of the lobbyists power and influence over the legislative process, and willing to applaud something not “less than perfect,” but fundamentally flawed and inadequate, simply because it’s possible. Somehow, this switching to the filtered brand argument doesn’t work for me when the issue is life and death.
    Rather than urging us to”all coming together,” I’d suggest that we continue this dialogue as a respectful and systematic argument about the actual effects and consequences of the proposed legislation, or, conversely, about who benefits and who does not.
    Frankly, none of us in this conversation has any real clout compared to those with money and influence in DC. But as intelligent observers who care deeply about our country, our health, and the costs to be borne by our children and grandchildren as a result of these decisions, we can bear witness and leave a commentary that suggests we sought the truth.
    With very kind regards, DCK

  67. Peter allow be to kindly point out a few corrections of your perception;
    Self Funded plans can cover individuals not in a group with changes to State Law and currently does cover individuals in one life groups. I think every company should sponsor a health plan with freedom to contribute what they can afford. This would give everyone access to the system.
    Yes there is cost cutting, I charge half what an insurance company does to administer. SF plans pay less in taxes, and our CEOs or the most part don’t make 7 figure incomes. But we also manage cost consideerably better then what carriers do, are more flexible, and more creative.
    Capitation is different then caps on Lifetime and annual maximums. People should not be reaching their max in the first place. Second as society we need to accept everyone can’t have unlimited care. Healthcare is like a teenager with mom and dad’s credit card, you have to place limits or it will bankrupt everyone. A sustainable system will have to deny some people care, the trick is to get the most out of what we can afford.
    Seld Funded plans look the same as Federal Plans also exempt from State Laws, as are church plans, and most Union Plans, are you overly concerned about the benefits offered to Union Members?
    Self Funded plans make the same changes fully insured plans make when they get 30% rate increase, the big difference, and this is a major point is SF plans actually have data so they know why their cost went up and how to directly address it where as fully insured plans are generally denied any data and left only with blindly cutting benefits or raising cost to employees. This is what allows SF plans to be so much more efficient, people are making informed decisions based on real facts.
    Your cash flow observation is actually the exact opposit. When you are fully insured you need 100% of the cost the first of every month. When you are self funded you need a fraction of the cost the first of every month and don’t need the rest until claims are actually paid. One huge selling point of SF is improved cash flow. Insurance companies hate not sitting on and investing clients money but contrary to what most people think I am not a big fan of insurance companies. A smart employer will fund to the max soit is there when they need it and if possible set up a trust to hold and invest claim reserves.
    The choice belief is also incorrect. We have and there are self funded plans offering all sorts of plan design options. I have small groups that offer more plan options then any carrier would ever allow. We are at this time unable to offer some of the alternative funding mechanisms we would like but that is State Law stopping that not the desire of the Self Funded plans. I have hundreds of ideas to control cost styimed by politician ignorance, capitating primary care being a great example of something we use to do before it was outlawed that I think could make a huge difference. Before providers and PPOs got in bed together we use to offer employees a choice of health systems which I would like to get back to. Guess I am reverting to my govt bashing but some things really are their fault.
    Always glad to answer any more questions on self funding as it really is a viable solution to almost every problem we face. Keep in mind self funding is really only a manifestation of responsibility, why self funding works is because people must get involved to do it, when people get involved instead of just writing checks to insurance companies and complaining these issues we face really aren’t that tough.

  68. I’ll offer my perspective on this.
    First, I think everyone agrees that the current system (status quo) is financially unsustainable. We also need to find ways to bring coverage to citizens and legal residents who currently don’t have it. ER care doesn’t cut it if you need cancer treatment or long term management for heart disease, diabetes, asthma, COPD, ESRD, depression, etc. At the same time, resources are finite under the best of conditions and the economy is currently in recession or just starting to emerge from it while the federal budget is far out of balance and likely to remain so even without a new entitlement program.
    With respect to the various healthcare and health insurance reform proposals working their way through Congress, I think it is absolutely clear that the costs, mainly for subsidies to help the uninsured acquire coverage, are certain to occur while the potential savings from tinkering with payment policy are far from assured to put it mildly. Costs are likely to be higher than estimated if the history of these programs is any guide with the exception of Medicare Part D. If middle class people are required to spend between 8% and 13% of their income to buy health insurance before qualifying for a federal subsidy, it will create a HUGE new incentive to hide or underreport income. Small employers, for their part, will have an added incentive to pay at least a portion of their employees’ compensation in cash and off the books. So, look for more people to qualify for subsidies than the experts estimate and more tax dollars to flow out as a result.
    While I recognize a need to define minimum acceptable coverage, I don’t think it is appropriate to preclude insurers from offering high deductible policies to people who want them and can afford to assume the risks. Personally, if I had the choice and I thought it would make economic sense, I would consider taking on a $10,000 per person ($20,000 per family) deductible with 100% coverage beyond that point as long as I was assured that I would pay the insurer’s negotiated rate for charges within the deductible. As a heart patient, I take $3-$4K worth of drugs per year to manage the condition. So, high deductible plans are not just a product for the young and healthy.
    In the meantime, as Nate and others point out, strategies to seriously attack costs are missing in action. We won’t see meaningful tort reform at the federal level from a Democratic Congress and a Democratic administration. We probably won’t get serious about going after fraud either. On the positive side, paying for palliative care consults in end of life situations is a good idea that I fully support.
    Finally, it’s interesting to note that the taxes to pay for the bill, whether it’s taxing so-called Cadillac plans or imposing an income tax surcharge on the wealthy are slated to take effect in 2011 but most of the benefits, including subsidies for the uninsured, don’t kick in until 2013. It’s interesting that it takes 10 years of taxes to cover the cost (hopefully) of 8 years of benefits, but as I suggested at the top, costs will probably exceed estimates, perhaps significantly.

  69. Actually Bev, Nate is almost making sense since he cut out the four letter words and the “guvmt can’t do anything right” diatribe. I do think that he sees self-funded plans as the savior as that’s how he makes his living.
    Nate, self-funded plans, which would not cover individuals not in a group, have to cut somewhere in order to maintain costs while operating in the same very expensive system we all operate in. You mentioned capitation of lifetime and annual claims, where would those people then find the resources to pay their medical bills once they’ve reached the max? Self-funded plans also it seems are not subject to state mandates, so just what do self-funded plans look like to employees, and I mean all employees, which means those that might be cut out of coverage for certain conditions? What changes do self-funded plans make to coverage when faced with higher than expected claims (discounting stop loss coverage)? And it also appears that employers need an extremely good cash flow to cover claims – which would cut out many employers. And of course employees don’t get choice in healthcare with a self-funded plan (also not in a company plan with traditional insurance) which is part of the argument with opposition to the present healthcare “reform”.

  70. not sure what that means bev M.D., not that you will read this of course. WHat has been stalled 21 years? Reform or the quality of care? 27 years would be 1982 in which time COBRA, HIPAA, MA, Part D, GINA, 4 or 5 major Medicare fee schedules changes at the federal level have all passed.
    I would strongly disagree with everything you just said. health care has not been stalled and getting a bill passed is what created any messes we have today, 27 years of terrible bills passing. To bad you won’t read this.

  71. Since I don’t read Nate’s comments any more, I don’t have to worry about whatever he said. But even he has to agree that, in the arena of health care which has been stalled for basically my entire 21 year medical career (+6 years of retirement), just getting a bill passed is a major miracle – that is, IF it happens. So yes, you are right, Matthew.

  72. Matt you and Maggie just can’t seem to grasp basic fatcs.
    “other than the exemption from taxes for self-insured groups which clearly discriminates against integrated systems and must go”
    You either don’t know how self insurance works or you don’t know what an integrated system is, either way you butchered the facts.
    Did you even read the article you linked or did you just not understand it?
    “State laws generally don’t allow these kinds of progressive provider payment arrangements in the case of self insurance.”
    The problem is not self insurance it is state regualtion and weak ERISA enforcement. I would LOVE to contract directly with integrated systems. In fact I would ideally love to cut out the insurance company all together and allow my employees to choose between competing integrated systems. Self Funded plans are already the most efficient plans in the country. If we where allowed to directly capitate providers there would be no touching us on efficency.
    Next self funded plans are alawys at the forefront of innovation, if you really wanted intehreagted plans to get a toe hold you would advocate for tax exempt self funded plans to be allowed to contract with them, they would grow quicker then any other legislation could grow them.
    “But what we’re going to get from the bills in Congress now is clearly better for poor and lower income people with health problems, and for small employers”
    Actually no this will kill small employers. Again your lack of insurance knowledge is betraying you. Right now some very sick people are priced out of the system. Others are forced to curtail their utilization in order to afford insurance. The current bills remove barriers to these groups participating and to any requirements they curtail utilization. This additional billions in consumed care must be paid by someone, that someone will be other small groups and individuals. Far from helping small employers it will drive more of them out of the system, just like every other effort at reform has in the past 15 years.
    Yes the uninsured sick will be able to get coverage for a couple years but then the cost will be as bad as it is now and they will once again be forced out.
    That’s not to say it couldn’t be done but the current bills repeat all the failed efforts of the past.
    FYI your item 2 diretly conflicts with item 1. If you remove rationing by financial ability to pay then you must ration someplace else. Either form of rationing by definition means people will be denied care they need. This is the common fallacy of liberal healthcare, its an unacheivable goal with no feasable path to existance. You try to write bills that provide everything for nothing then are shocked when they fail to deliver. No country in the world provides item 1 to their entire population. Most deliver 2 with only a small percentage of the population, the rich, having item number 1. As long as you continue to advocate and pass bills trying to achieve 1 & 2 you will continue to make things worse. Come to grips, admit no system can deliver both and figure out which balance you can live with. Once you define an acheivable balance then it would be very easy to design a system to acheive it.
    For 45 years since Democrats passed Medicare we have been bouncing back and forth between half witted attempts to acheive both. Democrats pass a huge bill to achieve 1 then when cost gets out of hand they pass another bill to achieve 2 which undoes 1. They then go back and try to legislate 1 again which breaks the bank and number 2. You have been playing ping pong with our healthcare long enough.

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