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.

Livongo’s Post Ad Banner 728*90

Categories: Matthew Holt

79
Leave a Reply

79 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
22 Comment authors
Common SenseHealth Care | Health Care GuideMikeinchoate but earnestMichael Kirsch, M.D. Recent comment authors
newest oldest most voted
Common Sense
Guest
Common Sense

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.”

Margalit Gur-Arie
Guest
Margalit Gur-Arie

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.

bev M.D.
Guest
bev M.D.

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… Read more »

Margalit Gur-Arie
Guest
Margalit Gur-Arie

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?

Barry Carol
Guest
Barry Carol

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.

bev M.D.
Guest
bev M.D.

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… Read more »

Margalit Gur-Arie
Guest
Margalit Gur-Arie

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….. 🙂

bev M.D.
Guest
bev M.D.

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.

maggiemahar
Guest

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.”

108DAYS
Guest

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.”

Health Care | Health Care Guide
Guest

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,

Barry Carol
Guest
Barry Carol

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.… Read more »

bev M.D.
Guest
bev M.D.

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… Read more »

Nate
Guest
Nate

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… Read more »

Margalit Gur-Arie
Guest
Margalit Gur-Arie

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