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An Alternative to Malpractice

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By JOHN GOODMAN

About three decades ago, University of Chicago law professor Richard Epstein proposed a radical alternative [gated, but with abstract] to our system of malpractice liability. He called it “liability by contract.” The idea: let patients and doctors voluntarily agree in advance how to resolve things if something goes wrong.

In nonmedical fields, Epstein’s idea is actually quite commonplace. Contracts for performance often have provisions detailing what the parties will do if something goes awry. If the parties disagree, contracts often spell out dispute resolution procedures (such as binding arbitration).

One version of this idea in medicine has already been tried. For years, hospitals asked admitting patients to sign a form agreeing not to sue the hospital or the doctors, no matter how negligent they were. When these forms showed up at the courthouse, however, judges routinely dismissed them on the grounds that the patients were too sick, too scared and too uninformed for there to have been a true meeting of the minds.

My colleagues and I at the National Center for Policy Analysis believe we have found here and here. Let the state legislature decide on the minimum elements (including the amount of monetary compensation) that must be in such contracts in order to make sure patients are fairly protected. Then widely publicize these elements so that people generally understand (before they get sick) what will happen if they opt out of the malpractice system. Courts would be required to accept these contracts as binding.

Continue reading…

Numbers Instead of Letters

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By KARI GORDER

780.4: Dizziness and Giddiness.

Deep breath: I still felt out of place. I turned the engine off. Quietly, I promised myself: once you get commissioned, maybe after you go through ODS, they’ll give you a Geneva Conventions ID card and you can stop showing your driver’s license at the gate. You’ll have a uniform and you won’t be the only one on base wearing jeans. You won’t have to be on a guest list.

I got out of my car and walked inside. The National Naval Medical Center was a labyrinth, but this was my third and final physical—putting a bow on the package, as my recruiter had told me—and I knew my way to the health center. As I sat between two men waiting for their pre-deployment physicals, I couldn’t have felt less proud. An academic in a hornet’s nest. But, I promised myself: one day you’ll deploy too—as a doctor—and serve your country. One day you’ll use the Arabic you spent four years in college studying. You’ll be able to tell your children that you fought in war. You’ll justify your departure from the intelligence community: to be one who does, not one who says. I thought of a picture hanging in my bedroom. Deep breath.

The path to a military scholarship for medical school is lengthy: background investigations, essays, fingerprinting. Letters of recommendations from current or retired officers; my grandfather wrote mine. A personal interview with a current military physician: I got taken out to lunch by a Navy doctor who also happened to be a reality star, and then got mentioned in a gossip blog. And of course, a slough of physicals. Today I was to go over the results of my blood work from the previous appointment, and sign the appropriate forms. My insurance company had faxed over the entirety of my medical records, including my broken arm at the age of 7. I was tying the bow. I wiped my palms on my jeans.Continue reading…

How to Blow the Big One: A Methodology

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By JOE FLOWER

[Note to the reader: Anything that is in italics and square brackets (such as this note) is addressed to you, personally. Yes, you. Try it on, see if it fits.]

Healthcare has, right now, the greatest opportunity we have seen in our lifetimes to make a big change, to rebuild itself in a hundred ways to become better for everyone, and cheaper—to get cheaper by getting better. We’re not talking “bending the cost curve,” cutting a few points off the inflation chart. We’re not talking a little cheaper, a little less per capita, a few percentage points off the cut of GDP that healthcare sucks up. We’re talking way cheaper. Half the cost. You know, like in normal countries.

We’re not talking a little better, skipping a few unnecessary tests, cutting the percentage of surgical infections a few points. No. Don’t even think about it. We’re talking way better. Save the children, help the people who should know better, nobody dies before their time, no unnecessary suffering. Seriously.

I don’t know how high you want to aim, but personally, I think we should aim at least as high as the cutting-edge programs and facilities that are already out there, in the system as it exists today, cutting real healthcare expenses of real people, even “frequent fliers,” by 10, 20, even 30 percent, while making them healthier, much healthier. At least. To me, that’s a wimpy goal, just doing as well as some other people are already doing. Because these programs are just getting off the ground. They’re in the first few iterations. The stretch goal, the goal we can take seriously, is to cut real costs by 50 percent, by making people healthier. There is at least that much potential out there.Continue reading…

The Fall and Rise of Asynchronicity

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By PAUL LEVY

The daughter of a friend was bemoaning poor connectivity of the internet at a university in Europe. She said, “It’s vital since I don’t have any other method of communication.”My friend noted, “I was telling her how we only had letters and occasional long distance phone calls in college….”

One of my most widely read blog posts was entitled, “Blackberry Cold Turkey,” in December of 2006. The impetus was when my telecom provider wrote in November to tell me that my bare bones wireless data service was going to be discontinued, but that I could “upgrade” to one with a higher price with more functionality, if I also bought a new device. I decided it was time for a life-changing experience and tossed my Blackberry in the trash. This reminded me of a major functionality of email.

The most important attribute of email is the asynchronicity of the medium: The sender and the receiver do not have to be in contact at the same moment. This enables efficient communication. You can integrate emails into the fabric of your life. You originate a message when you want, and you reply to another’s when you want.

Until the “revenge effect” occurs! How does this work? Email was invented. Then Blackberries were invented so we could be sure, when we are away from our computer, to receive emails as soon as they are sent and reply to them immediately. In fact, we feel compelled to read and respond in real time. Asynchronicity disappears.Continue reading…

My Own Story of ALS

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By AL LEWIS

I would like to introduce our newest regular contributor, Al Lewis. Some of you might recall him from his guest-postings, sometimes offensive, usually controversial but always based on both fifth-grade arithmetic and principles of economics, two subjects that he respectively took in fifth grade and taught for two years at Harvard.

Al is asking for a tiny bit of help from us, which is to go to his ALS site and “like” it and maybe add a facebook comment.   He is trying to get CMG Marketing (the official licensing contractor for Major League Baseball) to sell Lou Gehrig jerseys to raise money and awareness for ALS.  Increasing the popularity of that site increases the likelihood of his getting CMG’s attention with his fundraising idea. –  Matthew Holt

It occurred to me that I have yet to post my own story in detail, and some of you asked me to do that after seeing my wedding photo.

Janet and I had dated for a while, and though we had broken up, we had become more like “besties” when she started to feel that something was amiss.  I (and other close friends) took her to several doctors to try to discern what was wrong.   I know many of you experienced the same thing with your loved ones, where you had to visit multiple doctors before getting a diagnosis.   Then came the day — and no doubt you had a similar day too — when you finally get the definitive diagnosis.  The Mass General neurologist, Dr. Cros, had very thoughtfully scheduled this visit as the last one of the day, so that the four of us there could be in his office into the evening, asking questions, holding back tears, cross-examining him to make sure we hadn’t overlooked any possibility for treatment, even something in early-stage clinical trials, with mice even.

After that, we went about our lives.  Of course I continued to be supportive as best friends would be.  But I couldn’t stand to watch her deteriorate in front of me like this.     At one point her condition had declined so much that at her health club (Mt. Auburn) where she had been a member of for 20 years, someone asked what was wrong.  About a day after I told the person at the front desk, the manager wrote back and said he was going to comp her membership for the rest of her life.Continue reading...

Much More Reform Needed for Medicare?

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By ROGER COLLIER

This week’s startlingly gloomy annual report from the Trustees of the Medicare Trust Funds lent new urgency to the need for further Medicare expenditure reforms. Whether Washington DC politicians will respond with more than sound bites is less likely.

The Trustees’ report shows a dramatic deterioration—even based on the most optimistic assumptions— in the financial position of the Part A Trust Fund, along with expectations of continued faster-than-GDP growth for Parts B and D.

Compared with the prior year’s Trustees’ report, which forecast that the Part A Fund would run out of money in 2029, the latest report estimates that the fund will dry up in 2024—five years sooner. The reasons for the sudden acceleration of financial disaster include a significant drop in revenues from taxes on workers’ earnings due to the ongoing recession, and new forecasts of longer life spans for beneficiaries.

The report also includes new forecasts for Medicare Part B and Part D, which operate on a pay-as-you-go basis using mixes of beneficiary premiums and general federal monies. While Parts B and D will not exhaust their respective trust funds, they will have increasing impacts on the deficit as their federal subsidies are forced to increase. Medicare B costs are projected to grow at a 4.7 percent annual rate (based on current law), and Medicare D at a 9.7 percent rate through 2020, compared with forecasts of 5.2 percent annual GDP growth.Continue reading…

The System Firsthand

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By BRAD FLANSBAUM, DO

Grandma and me

Grandma is 93.  The matriarch of my family is in worsening health, and her decline is difficult to observe.  We all experience the travails of the US health care system at some point, and in my family’s case, ours is no exception.  The stress on my mom and aunt is considerable, and my grandmother is increasingly alarmed at her frailty and poor memory.

Through July of 2010, she was independent.  She walked daily, traveled, drove (that is another story), and enjoyed her brainteaser and crossword puzzles.  By all accounts, she was happy, albeit with the usual pangs of age.  She took no medication.

Last summer that changed when she fell and underwent a 3-day hospital stay.  Her memory was not the same and her gait was unsteady thereafter.  It was a minor stroke.

After discharge, her functional status worsened, and the vicious cycle we all witness as docs—setback beget setback—reared its head.

My mom sold the house, and grandma moved into an assisted living facility, a lovely place, but it was not home.  Her refrains, “the food and company are lousy, and I am depressed and lonely,” along with an assortment of other issues —all upsetting, given the vitality of this woman until recently—presented and intensified.  Relocation trauma is a known condition, but one you would differentiate only if you witnessed it firsthand.  I am now familiar with a (new) geriatric term.Continue reading…

It’s All Going According to Plan

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By JONATHAN HALVORSON

Most people regard health care reform in America as thoroughly bungled. The proverbial train left the station weak and wheezing, was pushed off the rails by hooligans and is about to crumple in an inglorious heap in the ditch. Only about 20% say the reform hits the sweet spot, with the rest convinced it went too far or didn’t go far enough.

To review the most recent pilings-on: in a time of huge Federal deficits, we get depressing predictions that the PPACA will do little or nothing to slow the growth of health care costs. Only a year after passage of what was supposed to be comprehensive reform, Democrats acknowledge that Medicare and Medicaid spending remain out of control and propose new cuts in the hundreds of billions. In the span of four months, Republicans switched from posing as aggrieved defenders of Medicare spending, to proposing to slash it and leave seniors to absorb the spillover. Medicaid funding is probably even more precarious, since fewer Medicaid recipients vote.

To add injury to injury, the Supreme court may rule to invalidate the entire law, or perhaps just the mandate to purchase insurance, thereby removing the most hated part of the law, but eliminating the “universal” part of universal coverage and inviting an actuarial death spiral. Oh, and the few reforms that look like they might bring costs down, like the IPAB board in Medicare and the minimum medical expense ratio for insurers, are under threat of being watered down. A year after legislation has been passed that will transform nearly a fifth of the American economy, to the casual observer it looks like nothing much has happened and nothing in the future is secure, especially anything that the big industry players don’t like.

In light of this and more, pessimism is understandable, but what we are witnessing in these turns of events is not mere politically-driven chaos. There is good reason to think that events are unfolding more or less in line with a staged strategy for deep reform that emerged out of the experience in Massachusetts. The strategy is essentially this: enact universal coverage first to precipitate a sense of crisis. This will lead to deep reform on the problem that exacerbates all other problems: the cost of health care. Readers of this blog need little reminding that these costs are twice as high as in any other nation.Continue reading…

When It Comes to Patient Safety, Caution Isn’t a Four-letter Word

By JORGO CHATZIMARKAKIS

Around the world and now in the United States, there is a broadening discussion of how best to proceed down the path of approving and getting to market medicines called biosimilars.  Biosimilars are non-identical copies of next generation medicines known as biologics.  As the U.S. begins establishing new guidance for biosimilars, regulators and legislators should look to the European Union model on guidance policy and approve these important, often life-saving, drugs when they are proven to be safe for the patients they are intended to heal.

There is justified debate and concern both here in the EU and other nations on how best to introduce biosimilars into the marketplace.  We know from the science, that it’s immensely more difficult to  produce a biosimilar than a generic version of a traditional drug.  And with this increased difficulty, comes increased risks to patients in the form of efficacy and drug-to-drug interactions.  However, by adding biosimilars to the treatment regimen, we can hope to see long-term therapy at the lower costs that biosimilars may be able to provide.  This is important to every country struggling to meet the demands of an aging population and rising health care costs.

As policymakers this dilemma is made easier because our focus must always be on patient safety.  Citizens trust that their nation’s regulatory bodies are looking out for their best interests and doing their due diligence to ensure a safe drug supply.  So patient safety is our starting point, our ending point, and our path along the way.Continue reading…

A New Cost Control Idea – Paying For Outcomes

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By JOHN E. MCDONOUGH

When it comes to reducing or controlling rising health care costs, we face a problem called “the fierce urgency of NOW.”

We have learned from the Medicare and Medicaid budget proposals by Rep. Paul Ryan, R-Wis., that Republicans have no substantive ideas on how to address these costs beyond shifting the bill to consumers and states. We also know that Democrats embedded a lot of promising ideas to generate savings into the health law — concepts ranging from medical homes and accountable care organizations to payment bundling and value-based insurance design. But these ideas will take time before we know if and how well they work.

But time is something we don’t have.

The federal government, states, employers and consumers are all struggling under the pressure of rising health care costs. For them, solutions can’t come soon enough.

State governments are facing a “Medicaid desert” between the end this year of the stimulus package’s enhanced federal matching rate and the 2014 implementation of the health overhaul’s Medicaid expansions. Some worry the sorry choices to address the funding shortfall will come down to cutting benefits, shrinking provider payments, hiking cost sharing and shredding eligibility. Proposals to control spending within Medicare have put that program equally in peril.Continue reading…