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Jun 22, 2009

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greensboro transplant

So, ed what are the economic principles behind obama's plan that will reduce costs, improve care, and increase availability?

James

Democrats are playing with fire here, and Hagan is holding some of the matches. If they fail to push through universal coverage ... my preference would be a single-payer public plan ... the electorate will rightly conclude that they are beholden to special interests.

Reducing costs will require changing how doctors are paid and how much care is delivered. The McAllen lesson shows us full well that more care isn't the same as improved care.

I personally don't believe we need improved care. I personally think our big problem is that we provide too much care, mostly in the last few weeks or months of chronic illnesses. Investing more there is stupid.

What we need is basic universal care for everyone. It is the moral position. The cost reduction comes from using evidenced-based medicine instead of profit-based medicine.

The US system simply doesn't stack up. It is out of control from a spending point of view, and doesn't deliver the value other countries experience. And for those who say "wait, we'll be rationing health care" ... we are already rationing health care - and it's going to get worse before it gets better. With boomers moving into their dying years, we are going to see pressures on costs that make today's challenges look like a walk in the park.

winstongator

JP - I think we do need improved care for many, especially the uninsured. Often improved care = cheaper care as the Frontline episode showed with the case of a woman with lupus.

The McAllen lesson focused on Medicare spending, and it has been put forward by some conservatives that if Obama thinks he can wring out 30% cost reductions, he should do it with Medicare first as a proof of concept. We have had many years of rising spending on health care, and the only substantial change to Medicare under Bush was to add a large component that really offered no cost control elements. If the cost of Rx drugs was deemed critical, then bulk pricing could have been enacted.

I would put the flipside question to conservatives. Their solution for controlling costs are high-deductable plans so that consumers see what things cost and decide against care that might not be necessary. How could that possibly contribute to controlling Medicare's costs? I think most conservatives see huge spending on health care as a feature not a bug. I would like to see primary care vs. procedure spending for those with low vs. high deductable plans, and the number of procedures that are done early in a year when someone switches from a high to a low deductable plan - I know I need a colonoscopy and I know I can switch from a high to low-deductable plan for next year, can I wait until Jan when my low-deduct. plan kicks in?

I agree that we spend too much in people's last days. There comes a time when you need a priest more than you need a doctor. Changing that spending category will involve philosophical discussions beyond taxing & spending levels.

James

Winstongator, yours is one of the most thoughtful and informative comments I've seen in weeks. Thank you.

I like the proof of concept idea on Medicare. Lord knows that ship is heading for the edge of the earth. But I'm not sure how the philosophical debate can be separated from the spending debate. Every body knows it's the elephant in the room. We quite simply pour far too many resources in the never-ending search for longevity.

Oregon's success in the "death with dignity" department should be extended to the entire country, of course, but that won't get us nearly where we need to go.

Bill Roper at UNC says that evidence-based medicine can go a long way to improving both quality of life and cost of care. He's right, but all the forces are aligned to fight against that rational view.

James

PS Conservatives really don't care about the issue. Their fight is an ideological one about keeping government small. Competence and effectiveness are irrelevant as long a some business somewhere is making money doing whatever it does.

If government proved it could rein in spending and cover everyone with basic, taxpayer-funded care in a satisfactory fashion, they'd hate the idea just because it's a government program. They feel about the government as a whole the way I feel about George Bush. He made me sick to my stomach.

No point in arguing with them. They're messianic about it. It's like debating religion ... not worth the trouble.

winstongator

The debate is not just between liberals and conservatives, but also within the Democratic party. There are Democratic senators that are against the public option and are not strongly for Medicare examining its spending.

I don't think Obama should have spoken at the AMA. They opposed Medicare and I believe Medicaid. They are concerned about malpractice legal damages, but have not really worked hard enough to eliminated malpractice. He would have been better off speaking to a group like the Amer. Academy of Pediatrics that acknowledges the utility of a program like SCHIP.

What I do not want to see is the payment for certain services reduced, as that will 'encourage' docs to do more of those procedures. Either the procedure is needed or not, and to a degree a slightly higher payment could help to make the decision to pursue a different, less expensive, course of treatment easier.

I liked the NYTimes article about rationing explaining, 'we already have rationing! But let's do smarter rationing!'. John McCain also explained how we also have universal coverage - everyone can go to an ER and be treated emergently, the issue of payment comes later! However, that is not a smart system, and it is always better to treat something before it becomes an emergency - like the case of lupus from Frontline.

Solving the McAllen problem is extremely difficult and I don't think Obama would be able to show results in his 1st term, so waiting for that to get done before implementing a broader coverage system would be a mistake.

Mick

Who decides what is "needed" and what is not and at what age is bypass surgety or stints become a luxury and not a necessity?

winstongator

Right now your doctor or insurance company decide what's needed. From the surgeon's mouth, via Gawande

"“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures."

More:

The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.

Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.

Often stents are used when diet & drug treatments can be as effective with less risk. What if you demanded open heart surgery and your doctor refused, only giving you a cath. Should a patient demanding OHS get it?

You're much more likely to get a stent in McAllen vs. at the Mayo clinic - do you really believe you're getting better care in McAllen?

Roch101

"Should a patient demanding OHS get it?"

Yes. If after listening to my doctors and considering whatever considerations may be mine, yes; if that is what I think is the best treatment for me, yes. That decision would not be mine to make under some public insurance.Of course, it is currently not mine to make either with Blue Cross Blue Shield. It is only ever going to be between me and my doctor if I can afford the costs out of pocket.

winstongator

Look at the above, physician provided example with gallstones. The question is do we, through medicare and our private insurance plans, want to pay for immediate gallstone removal? Or do we use some judgement and wait even if a patient is scared? The question of ability to pay out of pocket is irrelevant to that discussion.

Roch101

No, that question is not irrelevant, and it is where the left is tone deaf to the reasonable suspicions of the right on this issue, that of losing all ability to make any health care decisions independent of outside intervention. Should I want my gallbladder removed only because I'm scared or simply because I want to fry it up and eat it on Wonder Bread with Hellmans, if that is what I want to spend my money on and I can meet the price of a willing surgeon, that should be the end of it in a free society.

Ed Cone

Wonder Bread? I recommend fava beans and a nice Chianti.

Mick

I will look at my own family instead of the gall bladder episode above. My dad needed and received stents for his heart at age 68. He is still around and playing golf five years later. Without he would have passed away. Will that option be available under any, most, all single payer systems? Does anyone really know?

I hear horror stories from Canada and Britain (reportedly) of 55 or 59 being the cut off for open heart surgery, sents, etc. Any one know if true?


James

To my knowledge, no serious discussion of options would create a scenario under which people who want to spend their own money on stupid interventions, experimental treatment, personal vanity or whatever would be precluded from doing so. The argument is a red herring.

greensboro transplant

"PS Conservatives really don't care about the issue. Their fight is an ideological one about keeping government small. Competence and effectiveness are irrelevant as long a some business somewhere is making money doing whatever it does."

what a childish remark. why didn't you just post that conservatives really just want to kill children and make sure that old people eat dog food.

the private/public system is broken. the way to fix it is not government control of it. it is not to publicly pay for the care for more americans. it is not to force people to buy insurance.

when have these approaches fixed any system?

James

"Why didn't you just post that conservatives really just want to kill children and make sure that old people eat dog food."

What a childish remark. If I had wanted to say that, I would have. I meant what I wrote, and I have plenty of first hand experience with plenty of conservatives (my entire extended family) to know that my comment is more accurate than you imply.

I'd love you hear your magic answer about what to do. I support a single-payer public plan that operates like Medicare.

James

I'd love TO hear.

:)

Ed Cone

James, surely there are many conservatives who have genuine concerns about cost, quality, and availability of medical care.

Dismissing anyone who questions the mechanisms of reform seems unhelpful -- it just leads to off-topic fights about how terrible, or not, some large and vaguely defined group of people is.

Why not focus on the questions about the mechanisms instead? The stronger the case for a particular solution, the less resonant any argument against it based on ideology alone will be.

James

I was responding to WG's comments about the questions he'd put to conservatives:

I would put the flipside question to conservatives. Their solution for controlling costs are high-deductable plans so that consumers see what things cost and decide against care that might not be necessary. How could that possibly contribute to controlling Medicare's costs? I think most conservatives see huge spending on health care as a feature not a bug. I would like to see primary care vs. procedure spending for those with low vs. high deductable plans, and the number of procedures that are done early in a year when someone switches from a high to a low deductable plan - I know I need a colonoscopy and I know I can switch from a high to low-deductable plan for next year, can I wait until Jan when my low-deduct. plan kicks in?

In responding I was offering my view that putting that question to conservatives seems like a waste of time.

I have no doubt that many conservatives have concerns about cost, quality and availability of care. But I have yet to see any serious proposal put forth by right-leaning organizations that would do anything to address any of those issues. And when I talk to my conservative friends, their answer, as I suggested, is that the government should have no expanded role whatsoever. That leaves the problem to the free market.

When you take government involvement off the table, which is the core position of the libertarian right, what is there to talk about?

I may be wrong about this, but I will continue to hold down the left side of the debate with vigor. The discussion in Congress is at risk of sliding badly toward the muddled middle and someone has to stand for good old fashioned socialism. I'm happy to do that.


winstongator

I think JP's claim that conservatives are not interested in the issue of controlling costs is accurate. The largest expansion of government into health care was not done with much attention to costs.

Mick, glad to hear your dad's still golfing, but I find it hard to argue when you don't consider the example written by a physician, but will toss out hypothetical horror stories. The point is not that stents are not useful, just that sometimes equal or better outcomes can be achieved at less cost. My consistent scenario is the McAllen cardiologist recommending a stent (or other treatment), and the Mayo clinic cardiologist recommending a less expensive course of treatment.

We're also not considering a single-payer system, but a public health insurance option and supplement. Consider if your dad were 58 not 68 when he needed the stents and he was uninsured & didn't have the savings for them? The more you'll have to pay out of pocket decreases the likelyhood you'll go in to get something checked out, so the mild MI may turn into a massive MI that is either deadly or requires more expensive treatment.

Were the stents paid for by Medicare, pretty much a single-payer system?

greensboro transplant

let me be more specific...

"PS Conservatives really don't care about the issue."

that statement is false and offensive. conservatives care tremendously about the healthcare issue. i don't know anyone who thinks the current system is working. We don't believe in perpetuating the mistakes of the past.

"Their fight is an ideological one about keeping government small. Competence and effectiveness are irrelevant as long a some business somewhere is making money doing whatever it does."

this statement is a caricature of conservative beliefs and it's offensive. people who would elevate business success over personal and public well being aren't conservatives. they're nuts.

i don't have a magic answer. i don't think there is one. if so, some state or fed department would have grabbed onto it and shown us all up by now.

but i have principles that i believe need to be applied.

it all boils down to eliminating third party payer systems, increasing supply, stimulating competition, increasing personal accountability, and minimizing associated legal costs.

when those things occur, we'll see innovation like we haven't seen in 50 years. Costs will drop. Care will improve.

otherwise health care will become scarcer, more expensive, and poorer in quality.

winstongator

Would "eliminating third party payer systems" = eliminating Medicare? Medicare expanded over the past 10 years with little attention paid to using its scale to reduce costs. The only recent action taken re: Medicare was expansion, not towards cost efficiency.

Besides minimizing legal costs, the other points you list seem closer to magic than having a chance of actually happening.

James

Thanks for the thoughtful comment. I don't mean to be offensive, I'm just reporting things as I see them. Maybe I need to have more conservative friends like you.

Your comment about the principles seem generally right to me, but it's hard to imagine mechanisms that don't rely on serious government involvement.

Steve Harrison

"it all boils down to eliminating third party payer systems, increasing supply, stimulating competition, increasing personal accountability, and minimizing associated legal costs."

On that increasing supply and stimulating competition thing, I recently looked at some Labor stats that showed the health care industry/sector is the second largest employer (behind finance, I think) in the U.S., accounting for close to 14% of the approximately 150 million "working" Americans. And as my fellow unemployed will tell you, there are a crapload of job openings in the healthcare field right now, ranging from nurses to physical therapists to accountants to medical bill collectors, etc., etc.

For every nine people reading this, there's one who needs us to pay his or her salary. That's what supply and demand has done for our country.

Now, if you use the old "small town" analysis, could a town with a population of 1,000 economically support 70 health care jobs? Could a city of 10,000 support 700? No, they couldn't. We are addicted to medical care and the prescription drugs we expect/demand doctors prescribe for us, and that addiction requires maintenance, which brings us back to the doctors again.

I know that sounds simplistic, but we've created a monster. And that monster must be fed.

confused

Mick;
In Canada, age is not a factor (on its own) in deciding on heart surgery, etc. (if however, you're old and in poor shape that is different, although if the same would go if you were young and in poor shape).

Here's the BC Health Care system's synopsis:
http://www.healthlinkbc.ca/kbase/dp/topic/uf4513abc/dp.htm

Here are the wait times for care in BC
http://www.health.gov.bc.ca/cpa/mediasite/waitlist/median.html

Although anyone that needs emergency attention, gets it without waiting.

And here are the costs for health insurance in BC:

The monthly rates are:

$54 for one person
$96 for a family of two
$108 for a family of three or more

However, prescriptions are not covered, but everything else is -- you pay nothing else, no co-pays, no deductibles, not anything.

In addition, there are subsidies ranging from 20 to 100 per cent, based on an individual's net income:

$20,000/yr or less - 100 percent subsidy
$22,000 - 80 percent subsidy
$24,000 - 60 percent subsidy
$26,000 - 40 percent subsidy
$28,000 - 20 percent subsidy

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