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OFF-TOPIC: Wanna be ethnographed?

IFTF is looking for some volunteers to be ethnographed. Not as painful as it sounds—actually rather fun I did it a few years back.. They are currently recruiting for a new research study called "Boomers in the Next 20 Years". If you’re interested read on

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POLICY: Hoggy on Reggie

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For your weekend fun read—soon to be featured in THCB conservative—David Hogberg’s review of Reggie’s new book Who Killed Healthcare in The American Spectator. Hoggy of course thinks she’s too left-wing  in that she’s in favor of an individual mandate. Of course I haven’t ready this book yet although I’m prepared to guess what’s in it. Let’s just hope that Reggie’s next forecast is a little more accurate than this one she made in 1998.

As my book describes, the market forces that revolutionized the once-bloated U.S. economy are now reshaping health care. Activist consumers’ demands for accountability, convenience, and control are making the system more informative and accessible. The focused-factory concepts that revived the nation’s manufacturing sector and fashioned its world-class service sector are now shaping high-quality, cost-controlled health care delivery systems. And the sort of technological innovations that have increased productivity since the Industrial Revolution are improving the quality of health care while controlling costs. Brilliant entrepreneurs are using the managerial lessons learned from successes such as SamWalton to create a better, cheaper,more accessible health care system.

And just to be fair and a good sport this prediction stuff is very hard. So to prove it I’ll  lay some of my ghosts. The 1997 IFTF 10 Year Forecast for which I wrote the relevant part suggested rather more success in cost containment …although I had rather different reasons for thinking that was coming about. Here’s the most wrong part of the whole IFTF 10 Year Forecast:

The biggest change in the health insurance market over the past 10 years has been the fast growth of HMO enrollment. In 1998, more than 76 million Americans were enrolled in HMOs, and a majority were in some kind of a managed care plan. By 2005, HMOs will capture the majority of the commercial market and more than 25 percent of the Medicare market. Sixty percent of Medicaid recipients will be in some form of HMO by the year 2010.3 Among this plethora of new products, it will be increasingly difficult to distinguish one health plan from another. They’ll all offer similar—and often the same— providers and pay those providers through a mixture of discounted FFS and capitation (a flat fee per patient). By 2005, more than 100 million people will be in these “HMO descendants.”

The health insurance market will evolve into a mix of different health plan models, many of which will spend the next several years in a constant flurry of reorganization and mergers. Four dominant “intermediary” models will emerge by 2005: the case manager, the provider partner, the high-end FFS broker, and the safety-net funder. As a result, in 2007 close to 50 percent of the population will be in health plans for which cost containment is a key issue. Despite all the pressures toward increasing costs in the system, these new strategies will be successful enough to keep costs from exploding again as they did from 1960 to 1990.

 

POLICY/POLITICS: Clinton gets a little more specific

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Hillary Clinton made a major speech on health care yesterday. (Here’s the full text). Her quick points. Pay for preventative services (although what she’s talking about you’d recognize as DM), use IT and EMR, use the primary care “medical homes model” (the AAFP’s got to her!). Those are all strategies to save money—suspend your disbelief for a moment. Her other points are about changing malpractice and beating up drug companies on pricing. All very worth and all that but mostly rhetoric I guess.

Then more interesting stuff. Basically she wants a re-run of 1993–4. Big purchasing pools for small business. Guaranteed issue at community rating. Ending risk selection and underwriting. Unfortunately she uses a bad example by conflating cherry picking with insensitive network management/UR which are NOT the same thing:

In fact, according to a recent McKinsey report, insurance companies in America spend tens of billions a year figuring out how not to cover people — doing complicated calculations to figure out how to cherry pick the healthiest persons, and leave everyone else out in the cold. That is how they profit: by avoiding insuring patients who will be "expensive" — and then trying to avoid paying up once the insured patient actually needs treatment.

I see this all the time. My office spends countless hours arguing with insurance companies to get my constituents the health care they have paid for. For example, a father called me from northern New York — his son had a rare illness. Now he and his son were well insured. He’d worked for many years for the same employer who provided a good policy. But when his son needed a special operation — that could only be performed at one place in the country — the insurance company said, sorry, that’s out of network, we’re not going to send you to have that done. So my office intervened. And in the end they got permission for the operation. But I don’t think people should have to go to their United States Senator to get their insurance company to give them what they’ve paid for.

As President, I will end the practice of insurance company cherry-picking once and for all by allowing anyone who wants to join a plan to do so and prohibiting insurance companies from carving out benefits or charging higher rates to people with health problems.

She needs to find a new example to educate people as to what cherry picking is. Perhaps she should take Jon Cohn tour with her…. In any event that coverage denial piece will come back to bite her because her most interesting issue is her desire to establish a NICE type cost effectiveness institute which she calls the Best Practices Institute, and she gives a strong hint that it’ll not just be vetting new drugs for cost-effectiveness but also be using Wennberg/Dartmouth-type analysis as well as standard cost-effectiveness analysis to direct P4P. So of course there will be coverage decisions which may impact that constituent of hers with a rare illness…

It seems to me that she’s trying to get on the wave of employer discontent and then cut a deal with the larger insurers to let them stay in the game, and also let them blame the government (the new Best Practices Institute) for restrictions on coverage decisions. Not a bad political compromise perhaps. Of course the devil is in the details of the pools and the uniformity of benefits that insurers must provide.

And of course the real thing that needs discussion is the one thing she left out. How does this plan get the uninsured insured? It keeps the same employer payment format in place, and seems to have no mandate. Hillary is many things but dumb is not one of them. She must be focus grouping this next element to death, because ignoring it isn’t an option, even for as corporate a Democrat as she’s become.

Still, she’s revealed more than I expected her to, and there’s plenty here for her opponents on the right as well as on the left to latch onto. This is getting fun!

Abdullah and the Stonefish foot By Dr. Terry Bennett

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Terry Bennett is the last remaining solo GP in Strafford county, New Hampshire. He attained national celebrity two years ago after a patient complained to the state medical board when he lectured her about her weight. After fighting off the ensuing attempt to censure him, Dr. Bennett went on to become an outspoken advocate for reform in the medical education system. In the final analysis, he believes that medicine has been put in a box. And that it needs to be taken back out again. Today he shares a story about a long ago encounter that helped shape his views on the practice of medicine and his understanding of what it means to be a doctor. — John Irvine

It is Summer of 1988, and I am in Los Angeles, attending the Saudi Arabian National Cultural Exhibition. To the rhythm of drums, an old friend and patient is dancing with a line of other Saudi men. Nothing too unusual about that, it is part of Saudi folkloric behavior, the not-so-obvious-to-everyone-else-there exception, is that Abdullah A.R. is dancing on two flesh and blood feet, which appear completely normal, just like anyone else’s..

Now let me tell you why this is noteworthy.

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POLICY: Now I’m just messing with her

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So Amy Ridenour actually almost did what I asked and went and answered the questions for the free-marketeers I posed in Spot-on. My email has been broken all day and I’m grumpy, so I thought I’d cheer myself up by replying to her replies. This is mostly gratuitous dancing in the end zone on my part. So those of you who believe in the sanctity of erudite debate may want to skip it. The rest of you can join me in the gutter….

My questions from the Spot-on piece (originally titled “How to talk to a free marketeer”) are in red. Her replies in italics. My replies to her in regular text

“Why are you so happy to have a health care system that kills so many more people who have heart attacks, and amputates the feet of so many more diabetics?”

I don’t accept either of the two premises of the question.

Why not? The data—which I referenced in the Spot-on piece—comes from the Annals of Internal Medicine quoting the OECD. That shows that people suffering heart attacks are much more likely to die here than in Iceland, Denmark and Switzerland, and diabetics are much more likely to have their feet amputated than in Canada, Australia and a few other places. Is Amy suggesting that the statisticians in those countries and here are all lying in a massive fraud perpetrated by the Health Care Quality Indicator (HCQI) Project of the OECD? Funny, because that’s the same data source which produces those breast cancer survival rates that so many on the right wax all lyrical about. And if the data is right, why doesn’t America have a case to answer? We’ve heard enough about cancer care from the right!

And BTW the question has two halves but only one premise! To be clear—it’s not logically consistent to say we’re the best at treating disease by only looking at one or two diseases!

“Ask the free marketeers to explain why they feel comfortable with a financing system that causes at least 25% of all the nation’s bankruptcies.”

Same answer as above.

The same answer as a non-answer? Pretty curious. Perhaps health care costs don’t actually cause bankruptcies, or at least not at the 50% rate that Himmelstein and Woolhandler claim. But the 25% number comes from the reworking of the 50% number by Dranove & Millenson, which was in part funded by AHIP. So even they acknowledge that it’s a problem? But Amy “doesn’t accept it”. Can’t argue with that logic, I guess. I mean you literally can’t argue with it!

“Why [do free marketeers] espouse even greater cost sharing even though it’s been shown yet again this week that increased payment at the point of care reduces people’s likelihood of following their doctor’s advice?


One argument for “letting” people control more of their own health care spending is that the people who earned the dollars have the highest moral right to decide how they are spent.


So now it’s about the moral right to spend your money the way you want. I have no problem with that. Unfortunately those like Amy occupying the high moral ground don’t seem to care that the little people who have to choose between spending money on doctor visits and drugs or on food or rent—and yes there are some—are likely to not take their drugs or get needed care. She may feel all moral and good about that, but there are direct consequences. The most obvious being that more expensive things need to be done to them later (like the diabetics getting their feet amputated). Which of course the little people don’t pay for (at least not monetarily), but the rest of us do. But I’m glad she sees the moral rather than the practical effect of cost sharing at the point of care.


Another argument, which Matthew Holt presumably knows already, is the theory that folks who are spending their own money will shop around for the lowest prices, thereby adding incentive for health care providers to keep prices competitively low.


And while we’re at it, which country has the highest prices at the point of care for drugs and office visits? And which one has the highest proportion of consumer spending out of pocket on those drugs and office visits? Could it be that it’s the same one? As in this one. And how does that work in Amy’s theoretical model? Maybe she’ll enlighten us.


“Why do you want to raise taxes in order to transfer money from the poor and sick to people who are already richer and healthier than average?”


I don’t. Nor during my working lifetime have I seen many examples of tax increases afflicting primarily the poor and the sick (though perhaps tobacco tax increases could be considered an exception; those of us who opposed those, however, were considered to be puppets of Big Tobacco). My primary health care concerns are these: I oppose a U.S. adoption of a government-run, so-called “single payer” or “universal” health care system because I believe it would lead to needless misery, pain and death. I also am extremely concerned about Medicare’s poor financial prognosis (which I also believe will lead to an ever-worsening standard of care under Medicare). I do not believe that my position on either of these means I “want to raise taxes in order to transfer money from the poor and sick to people who are already richer and healthier than average.”


Now I’m a dumb guy so I’m having trouble following Amy here. It’s good that having criticized me for using the terms “screwed up” and for being “emotional” she remains so coldly analytical while accusing universal health care of causing “needless misery, pain and death.”


But original question was unconcerned with the desires of evil government single-payer bureaucrats to ration pre-natal visits for the first 10 months of pregnancy and the like. Instead it referenced the desires of some on the right to give everyone their own personal account with all the nation’s health care dollars divided up proportionally in it. I simply pointed out that if we do that, then money that previously would be spent on health care would instead remain in the accounts of those who are healthier and wealthier than average. If we were to continue to care for the sick in such a system then someone would have to pay the equivalent that’s now sitting unused in those accounts to cover it. That someone would either be the sick themselves, or the taxpayer or both. In my humble economics, that’s a transfer away from taxpayers (who are presumably of average wealth and health) and from the sick (who are of less than average wealth and health) to those who are healthier and wealthier. Amy may not believe that this is a good idea, but in that case she should refute the personal account concept and join those of us who believe in a social insurance model as being the only effective way to pay for health care. I somehow doubt that’s where she’s at.


So there you have it. All my questions completely answered to the satisfaction of anyone who doesn’t care about logic, health services research, or reality. The rest of you may be awaiting her man Hoggy’s shot at it coming soon.


And for those of you who really can’t figure out what “rent-a-quote” means, look at this obituary.

POLICY: Doing my bit to piss off the unthinking right

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Cool. I make an off hand remark about conservative think tanks and get them all riled up. Amy Ridenour, who has an interesting place in the panoply of right wing think tanks and influence peddling, prints an email I wrote her and tries to answer my questions. I’m sure Mr Scaife thinks his money is well spent.

Of course what my piece was doing was directly stealing the conservative right’s tactics of changing the debate. Except in my case I’m doing it logically.

For instance, the right called inheritance taxes “death taxes” suggesting that they fall on everyone who dies—even when only a tiny minority pay them. So the law is changed and a mythical family farm is saved, and so funnily enough is the family fortune of the Waltons and their billionaire friends.

Similarly the right has been attacking foreign countries for alleged sub-standard care, and using that to justify our appalling health care financing system. All I’m doing is asking them to defend the care here that’s found to be of a worse standard. And of course Amy can’t. Perhaps her man Hoggy can. I’m looking forward to his response!

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