August 3rd, 2009 by Happy Hospitalist in Better Health Network, Health Policy
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With regards to a compromise by Blue Dog Democrats on setting the rates for paying doctors:
Waxman’s committee resumed work Thursday, with the goal of finishing Friday, after a week-and-a-half delay caused by objections from fiscally conservative Democrats. That rebellion was quelled with an agreement Wednesday that would protect more small businesses from a requirement to provide insurance to their employees, and restructure a new public insurance plan so it could pay higher rates to doctors and other providers, among other changes.
What did the the other Democrats have to say about that?
“This agreement is not a step forward toward a good health care bill, but a large step backwards,” 53 Progressive Caucus members said in a letter to House leaders Thursday. “Any bill that does not provide, at a minimum, for a public option with reimbursement rates based on Medicare rates — not negotiated rates — is unacceptable.“
Let me get this straight. In a world where Medicare and Medicaid pays less than cost, these Democrats want an option where doctors have the opportunity to lose money for every patient they take care of? If negotiated rates are unacceptable, exactly how is the Medicare rate acceptable. There is a reason why many Medicare and Medicaid beneficiaries cannot find a doctor to take care of them. Because the non negotiated rates are unacceptable.
Perhaps our Congressmen and women would like the 300 million Americans to take a yearly vote on the value of their service to this country. No negotiation. Majority salary wins. You just may not like what your constituents are offering you. And you just might quit. How’s that for unacceptable.
*This blog post was originally published at A Happy Hospitalist*
August 3rd, 2009 by KevinMD in Better Health Network, Health Policy
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Reducing health spending, as Congress is finding out, is difficult.
Some health economists have pointed to medicalization of common complaints, like erectile dysfunction and attention deficit hyperactivity disorder, as one reason. Indeed, Dartmouth researchers, who are cited as favorites of the current administration, feel that an “epidemic of diagnoses” is what’s making us sick.
But, Darshak Sanghavi writes in Slate that this may be a red herring, and clouds what’s really driving up costs, namely, the amount we spend prolonging the lives of the elderly. He points to David Cutler, an adviser to President Obama, and his analysis that “it costs far more to prolong the lives of the elderly ($145,000 per year gained) than the young ($31,600), and the rate of spending on the oldest Americans has grown the fastest.”
None of the current health reform proposals target this, understandably, because it would be politically difficult to tell elderly voters that we need to spend less on their care.
And because of that, Dr. Sanghavi rightly concludes that, no matter what gets passed, “we’re just putting off the day of fiscal reckoning.”
*This blog post was originally published at KevinMD.com*
July 31st, 2009 by Happy Hospitalist in Better Health Network, Health Policy
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Cost is the enemy here. via the WSJ blog
“If we do not control these costs, we will not be able to control our deficit. If we do not reform health care, your premiums and out-of-pocket costs will continue to skyrocket.
…if somebody told you that there is a plan out there that is guaranteed to double your health care costs over the next 10 years, that’s guaranteed to result in more Americans losing their health care, and that is by far the biggest contributor to our federal deficit, I think most people would be opposed to that.
Well, that’s status quo. That’s what we have right now.”
Proponents and supporters can argue forever about whether this is the fault of the free market or the fault of too much or too little government. I happen to believe that what we have today is nothing more than an expected result of the government regulations put in place. No matter how you try and structure regulation, capitalism will exploit it.
Every insurance I am involved with has a beginning and an end. If your house burns down, you get a defined compensation. If your spouse dies, their life insurance pays a defined compensation. If drive your car into a garbage can and dent the hood, your insurance pays a a beginning and an end.
With health care insurance, we haven’t defined an end point. With fee for service, the costs are unlimited, and therefore our health care inflation is unlimited.
With bundled care, the costs are limited, and there fore our health care inflation is limited as well. Some folks believe that you can’t estimate how much it will cost to take care of a patient with diabetes with complications, coronary disease and six other chronic medical diseases. I think we can. And I think we can do it much cheaper than we are doing it today.
The current model is not sustainable. In any third party model, whether it is the government through taxes, or private insurance through premiums, no one is accountable to cost. FREE=MORE makes providers do more. FREE=MORE makes patients do more. I have come to the conclusion you can’t have both fee for service and third party insurance AND not double our expenses in the next 10 years. I personally do not want to spend $25,000 on myself and Mrs Happy’s health insurance in ten years.
Obama is right. This is exactly where we are heading. Remember that $25,000 in health care insurance is $25,000 less in take home pay being withheld by your employer. As long as someone else is paying the bills, FREE=MORE will prevail and we are all screwed.
Either abandon health insurance all together, or abandon fee for service. We can’t have both and survive.
*This blog post was originally published at A Happy Hospitalist*
July 28th, 2009 by Shadowfax in Better Health Network, Health Policy
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From the department of “Credit where it’s due,” in the comments of my
post on the Lewin Group, Nurse K pointed out the following:
Come on Shadowfax, you’re blogging about this stuff and you stand to make A TON of money if it goes through…for awhile…until insurance companies decrease your compensation since you’re making more per patient. I know you mentioned this before in like a comment or something, but ER docs stand to benefit (temporarily) probably more than anyone else. HUGE bias on your part.
Much as I (really, really) hate to admit it, she’s absolutely right. In fact, I’ll go one further: I first got interested in this part of medicine policy because I was mad that I was seeing all these uninsured patients and wasn’t getting paid a thing for my efforts. I started keeping track of the number of uninsured I saw every day, just as a pet obsession. It was a sobering number. After that I started getting a little perspective, talking to patients and seeing their bigger picture, understanding why they were uninsured, learning the particular challenges they faced getting health care, etc. For me, this cause became something beyond the personal a long time ago and became a moral imperative.
But K is right to note the potential for bias, and it’s fair for me to acknowledge it. I hope that my integrity on this point is evident. The fact that I argued in the New York Times for an increase in primary care compensation, with an attendant decrease in the compensation of specialists, including Emergency Medicine, should speak well for my ability to see beyond personal self-interest. (God knows it didn’t make me popular in EM circles!)
This is something which struck me yesterday, reading the med blogs reaction to Obama’s presser. Quite a few docs mounted their high horse and with great indignation denounced this:
Doctors are forced to make decisions based on a fee payment schedule that’s out there. So they’re looking… if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, “I’d make a lot more money if I took this kids tonsils out.” Now that might be the right thing to do, but I’d rather have that doctor making those decisions based on whether you need your kids tonsils out…
Now it’s a clumsy clinical scenario written by someone who has no clue about medicine. But it’s a damned fair point. Bias comes writ large, as in the Walter Reed orthopod who pocket $850K and falsified his research to benefit Medtronic, and it comes writ small, as in the ER doc who sees a small lac and has to decide whether to use a band-aid or a stitch, knowing that the stitches will pay 10x more. It comes with the cardiologist who has to decide whether to take a low-grade troponin leak to the cath lab. It comes with the surgeon seeing a patient with unusual abdominal pain and a slightly enlarged appendix on CT (you can observe or just take out the appy; guess which pays more).
Whether there’s a “fix” for that in the current reforms is debatable. It harms our standing, however, to deny the possible existence of bias and to claim a moral purity that, as a profession, is not justified. I think and hope that most of us in these ambiguous situations are able to come to the right decision for the patient the vast majority of the time regardless of our economic interests. The best way to remain credible is to acknowledge the mere potential for bias and move on and debate the salient point. Making counter-factual arguments that biases do not exist or that we physicians are too awesomely altruistic to ever be influenced by them does nobody any good.
*This blog post was originally published at Movin' Meat*
July 27th, 2009 by DrWes in Better Health Network, Health Policy, News
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Yesterday in our cath conference, we discussed the substudy from the prospective randomized trial called PREVENT-IV just published in the New England Journal of Medicine. That study evaluated the major adverse cardiac event rates of minimally invasive vein harvesting compared to open vein harvesting prior to coronary bypass surgery.
I was surprised to see that minimally-invasive vein harvesting had a higher combined complication rate of death, myocardial infarction (heart attack) and need for revascularization in the patients who received vein grafts harvested by the minimally-invasive technique. Following the presentation of the data, our surgeons were asked why this might be the case. While none knew for sure, they postulated that the art of harvesting vein-conduits using endovascular techniques might play a role (it’s more difficult), or the effects of the thrombolytic state induced by on-pump bypass vs. off-pump bypass might create the discrepency in post-surgery vein survival, since patients are less likely to develop clinical thromboses in the post-open chest bypass population.
So this morning, I was surprised that President Obama toured Cleveland Clinic yesterday and had such an up-front experience with minimally-invasive robotic surgical techniques for mitral valve repair that hardly represents mainstream American health care. While the marvels of the technology cannot be disputed, like the endovascular vein harvesting study above, might we find that robotics could be as deleterious to patients compared to open chest techniques? After all, these techniques have yet to be compared in multi-center trials to more conventional open techniques for mitral valve repair. But more concerning as we move forward is this question: will academic centers be granted more funds to test comparative effectiveness research for robotics at the expense of front-line American health care? Surely, this won’t be, will it?
Probably.
But when I see pieces like this I wonder why the article does not question the cost and risks of this technique compared to conventional open-chest procedures, especially in this era of touting the need for health care cost containment. How much is this piece about the marketing of this technique to the community (for financial gain) or to the President (for obtaining grants or political favors)?
Perhaps we should ask ourselves how many of the physicians and surgeons at Cleveland Clinic stand to earn a seat on the proposed MEDPAC board that will determine if Congress will approve payment for robotic techniques even when few data exist to show their superiority over conventional techniques.
Now that might make for some really interesting reading.
*This blog post was originally published at Dr. Wes*
