August 4th, 2009 by DrRich in Better Health Network, Health Policy
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Before the election, the right-wing commentators insisted to us that Barack Obama was a closet socialist. They hounded us repeatedly with the notion that Mr. Obama hung out with the likes of Jeremiah Wright and Bill Ayers, and that in fact virtually all of his acknowledged friends and advisors were dangerous leftists. When Mr. Obama innocently told Joe the Plumber that he wanted to “spread the wealth around,” you’d have thought he’d announced his intention to replace the Constitution with the Communist Manifesto.
And the righties have been even more vociferous since President Obama took office. In high dudgeon they beseech us to notice (dear God!) that in six short months he has gathered into the grasping embrace of his government a good chunk of the American economy, from GM and Chrysler, to Fannie Mae and Freddie Mac, to the world’s largest banks and investment houses – and in short order he intends to take over the entire healthcare system, now fully 16% of our economy and growing rapidly.
At the same time (they insist) he is doing everything he possibly can to stifle American business. He is raising business taxes during a deep recession, and is pushing Cap and Trade, which will put American businesses at a huge disadvantage in the world market. They say that the massive deficits Mr. Obama is accumulating at unprecedented rates will place our economy in grave jeopardy within a decade, and that our children and grandchildren will never be able to extricate themselves from the pit of debt he will have left them. They point out that Fidel Castro and Ceasar Chavez, avowed Communists, look at Mr. Obama’s doings with great awe and respect bordering on jealousy. The right-wing commentators say lots of other stuff, too, to prove Mr. Obama is a radical lefty, but for DrRich all these allegations blend together after awhile, and it becomes difficult to recall the specifics. (One thing they hardly ever mention is that the first step in the Great Government Takeover of Everything was taken by President Bush. Mr. Obama has merely accelerated the pace down this path from a saunter to a sprint.)
DrRich must admit that, even for someone as objective and open minded as he is, it can become easy to view the incredible flurry of policy achievements Mr. Obama has pushed through so far, and his aspirations for even bigger ones still to come, and wonder whether, perhaps, this great experiment of unprecedented government spending, and huge new entitlements that will continue on down through the generations, might not be just a tad risky.
And it is even more disturbing to consider that, if one indeed wanted to bring down the American system in order to have the opportunity to remake it from scratch (this time, emphasizing equity of outcomes rather than individual freedom as a central organizing principle), then burdening the system with crushing entitlements and crushing debt would seem to be a pretty serviceable method for achieving it. And this is exactly what the right-wing commentators would have us believe is President Obama’s real aim. (Which is why, they say, they dare commit the very grave sin of publicly hoping President Obama will fail. Only Democrats, it seems, are permitted, with political correctness, to voice such hopes about opposition presidents.)
So even DrRich (a paragon of objectivity) was beginning to have his doubts about Mr. Obama’s real commitment to the American experiment.
But in his press conference last week Mr. Obama allayed all DrRich’s fears, and made him ashamed he had ever entertained such doubts. If he really meant what he said in that press conference, it is impossible for President Obama to be a radical leftist.
Recall his typically eloquent words: “You come in and you’ve got a bad sore throat, or your child has a bad sore throat or has repeated sore throats. The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’”
Now, don’t you feel better? DrRich certainly does.
Of course, certain short-sighted physician groups immediately and unproductively took offense at this comment. There is no reason to. After all, Hillary pronounced 16 years ago that the problem with the American healthcare system is: Too many greedy doctors using too much expensive technology. And that’s pretty much been the sum of it ever since.
So even if Mr. Obama meant to insult doctors with his comment, he was simply restating one of the chief premises dearly held by most healthcare reformers. He wasn’t breaking new ground in any way. So doctors shouldn’t be acutely insulted here. (They should be chronically insulted. )
If there’s anything to regret about Mr. Obama’s statement, it’s that it reveals a sad misunderstanding of one important aspect of how the healthcare system works. Kids with sore throats don’t go directly to the greedy otolaryngologists, the guys who get paid “a lot more money” if they take the kid’s tonsils out. Rather, they go to primary care doctors, often pediatricians, who (if anything) are punished for sending too many kids to the greedy otolaryngologists. (DrRich knows several fine pediatricians, and not one of them any longer possesses those nasty looking tonsil scoops, or whatever those dire instruments are called which are used for removing the offending glands.) So the system is actually geared toward having kids suffer with chronic sore throats until the PCP just can’t ignore the problem any more. The ones who are finally referred to the greedy specialists often really, really need to have their tonsils out. The pediatricians aren’t referring patients for tonsillectomy all willy-nilly, and the greedy otolaryngologists (even if one supposes they always rip tonsils out first and ask questions later) must find other means of paying for their speedboats. DrRich’s point being: In the real world, using the abuse of tonsils as an example of run-away healthcare spending just doesn’t work very well.
It seems a shame that Mr. Obama does not have even a basic understanding of the system of incentives that exists today within the healthcare system, especially since he aims to fundamentally change it. But then, since he allows that he hasn’t even personally read the healthcare reform bills he’s urging Congress to make into law, one cannot really expect him to have an intimate understanding of the present system, which he hopes to soon render obsolete anyway. It would be a waste of his valuable time to come entirely up to speed on a system which is apparently in its last days.
Back to the point of this post, and it’s a point that – sad to say – every other commentator seems to have missed. (Proving, once again, how lucky DrRich’s readers are to have him.)
When President Obama declared that greedy physicians will commit surgery on unsuspecting and innocent children just because the reimbursement rate is higher, nobody seems to have noticed that what he was saying was, “Doctors respond to fiscal incentives.” And since a committed egalitarian like the President would surely not believe that doctors are fundamentally different from every other type of human person, he was really saying, “People respond to fiscal incentives.”
There it is. Mr. Obama explicitly and publicly believes the one thing that no committed Communist or radical leftist is permitted to believe, namely, that people respond logically to fiscal imperatives.
Fundamentally, socialism requires people of ability to work very, very hard for the public good, to support those who cannot or will not work hard, and as a reward they can expect to receive praise from the ruling class.* Knowing their toil is for the good of everybody should suffice as incentive aplenty. This is precisely why radically left-wing social systems (which DrRich has always thought in principle to be a very nice idea) have never worked – and never will work.
For no system of societal organization can work well for long that requires, as a first premise, a fundamental change in human nature.
So right-wingers who have railed against the overt left-wing policies of Mr. Obama, and the more moderate people who have been starting to have their own doubts, should now breathe a great sigh of relief. Whatever else our President may be, he cannot be a committed leftist.
Even though the cost of learning this vital fact was another insult to the basic integrity of doctors, it was really just one more insult superimposed on a world view that defines doctors to be fundamentally greedy and inconsiderate of their patients’ actual needs. No big deal. For the cost of that small price, we now know that President Obama must be – has to be – a committed capitalist after all.
*In practice, of course, those who take risks and work hard for personal gain are never actually praised for their contributions to the public weal, even if those contributions are enormous and stifling. Rather, they need to be demonized; otherwise some would think it unfair to take their hard-won gains from them.
*This blog post was originally published at The Covert Rationing Blog*
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 25th, 2009 by Emergiblog in News, Opinion
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I was honored to receive an unprecedented opportunity to hear a Senior Advisor to President Obama speak about his health care reform efforts at BlogHer 09.
Valerie Jarrett, Senior Advisor and Assistant to the President for Public Engagement and Intergovernmental Affairs, spoke to an intimate group of bloggers at a luncheon today.
And I was 15 minutes late.
How humiliating! This was definitely not the event where one should be “fashionably late”.
Ms. Jarrett was totally cool though, and said “Come on in and tell us who you are!” Apparently I had just missed intros; the discussion was just starting.
(Photo credit: Wikipedia)
********************
Now I’ve been pretty clear about not wanting a government run health care system, and I attended the luncheon knowing I did not have a clear grasp on the President’s proposal. (I have downloaded the Bill, have not had a chance to finish it.) I wanted to keep an open mind; I wanted to learn as opposed to opine.
The best way to learn is to keep your mouth shut and listen. That is exactly what I did.
It was not easy.
*****
Ms. Jarrett is warm, sincere and truly passionate about the President’s efforts at health care reform; Ms. Jarrett has full faith in the ability of the President to positively reform our health care system.
Now, if I heard and understood correctly, what the President wants is a public plan as an option; a choice to obtain health care coverage through the government should you find yourself unemployed/without any health care coverage. Ms. Jarrett was adamant that the goal is not a single-payer government run plan, but there was some group questioning of (1) why the idea of a government plan is perceived as scary and (2) whether or not it would be tantamount to socialism and indeed, what would be wrong with that anyway. One blogger noted that she knew many Canadians who were happy with their health care.
These questions were more rhetorical in nature. Honestly, I don’t think time would have permitted in-depth discussion.
*****
There was discussion on how bloggers can get out the message of health care reform and ideas on how the President can best communicate his ideas to the public. It was noted that the President is holding press conferences for which he is asking full coverage because he wants the entire story told, not just sound bytes. (Side note: I found this interesting because just recently ABC News encamped in the White House for an entire day – and the topic was health care reform.)
I actually did have a question enter my mind, as I was intrigued by the idea that the public plan was an option: I wanted to know if one could move in and out of the public plan as desired, or were you stuck in the public plan once it was chosen.
I didn’t get a chance to ask, as the discussion moved forward with two bloggers sharing stories of their personal experiences with the health care system. Very personal, heart wrenching stories. Their frustration and anguish was palpable. Ms. Jarrett listened with empathy; she truly cared about what my fellow bloggers had/were enduring.
I found out later that both bloggers left with her personal business card with her office number for them to call her directly after the conference. That was impressive.
*****
So, some final thoughts.
I like Valerie Jarrett. It was amazing that she took time to come and speak to us, and it was informative. She speaks straight, she is sincere and she seems very passionate and compassionate regarding health care reform. I’m a bit more informed about what the President is looking for. This was the advantage shutting up and listening. I don’t necessarily agree but I’m starting to at least get a hold of the concept.
Gratuitous political commentary: I think a little too much time was spent decrying the last administration. It’s over; time to move on.
Now for my totally off-the-cuff observation. I could not help but notice this was the exact opposite of my experience in DC last week. This was a full-on Obamafest, last week seemed like an “anything BUT Obamafest”. This week the “opposition” was putting out misinformation, last week the “opposition” was trying to cram a bill through before Congress could read it.
Is there no middle ground? Does it have to be this contentious? Maybe it’s the way of politics and I’m just now realizing it.
Between the two events, I guess I have now been exposed to a “fair and balanced” view of health care reform by Washington insiders.
So….why does it still feel like I have vertigo?
*****
This post was written from my own notes and memory. It was actually live-blogged in real time and if you would like to read the entire transcript, it is written here: Valerie Jarrett/Health Care Reform Live Blog BlogHer 09.
Valerie Jarrett, White House Senior Advisor Talks to Bloggers at BlogHer09
*This blog post was originally published at Emergiblog*
July 13th, 2009 by DrRich in Better Health Network, Health Policy
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Even with the soaring popularity of our new President, and the general feelings of goodwill projected toward him by Americans and non-Americans alike, and despite the fact that the party he leads holds large majorities in both houses of Congress, and despite the general agreement by both political parties and by all the major stakeholders in the healthcare universe that the time has finally arrived for substantial reform, one gets the sense that Mr. Obama is losing some of the initiative on his healthcare reform plan.
Some of the leaders in the Democratic party (who, really, are the only ones who count) have balked at the price tag that has been attached to the Obama proposals (estimated currently at $1.5 trillion over 10 years, and most admit this projection uses the rosiest of assumptions), and now they’re balking as well at the much-desired (by the Obama administration, at least) “public option,” the Medicare-like insurance plan for all.
Worse, new schemes for healthcare reform – schemes which differ in fundamental ways from the Obama proposals – seem to be springing up all the time, and furthermore, many of these new proposals seem to be taken seriously by the press and by members of Congress. Even if none of these new plans ever ends up going anywhere, the mere fact that people in positions of authority are calling for them to receive honest consideration is a strong indication that the Obama plan might not come to a vote any time soon.
It is also a sign that Congress might be balking a bit, preparing to break sacred protocol, and actually preparing to subject any healthcare reform bill to careful consideration and debate prior to voting on it. Such action would be in stark contrast to the now-standard practice – honed with the TARP bill, the first (and one prays, only) stimulus package, and (in the House) the Cap and Trade bill – of voting on major legislation without a single congressperson taking the time to read it.
It seems clear (to DrRich at least) that the administration’s overarching strategy is (while invoking a sense of ultimate urgency), to ram through all of its incredibly high-cost policy initiatives, before the general sense of crisis and panic among the populace dissipates, and before sober reflection reveals to us that we’re already hamstringing our posterity with crippling debt. (Our motto: What’s our posterity ever done for us, anyway?) So any delay can only spell trouble for the Obama health plan.
Fortunately, DrRich is here to reassure the Obama administration that the thing is still well in hand. While the road may be a bit bumpier than you might have hoped, it still leads where you want to go.
To see why, one simply needs to consider for a few minutes those alternate reform proposals now circulating amongst policy wonks. DrRich will briefly describe three of these alternative proposals, ones that seem to have gained at least some traction, and which may on the surface seem to be quite good (and thus the most threatening to the Obama plan). Then he will demonstrate why these plans simply cannot work.
The Healthy Americans Act, sponsored by Sen. Ron Wyden (D-Oregon), requires that individuals buy private health insurance that at a minimum would offer “Blue Cross standard” care. Individuals would be able to afford this insurance (which will be available to all regardless of age or medical history) because everybody would get a big raise (by statute) when their employers no longer have to buy it for them. People earning less than 400% of the poverty level would receive government subsidies to purchase their own insurance. The Wyden plan has the great advantage of having been “certified” as being budget-neutral by 2014 – so “officially” it would be a trillion or two cheaper than the Obama plan over the next decade.
The Patients’ Choice Act, sponsored by four Republican Congressmen (Coburn, Burr, Ryan and Nunes), also places ownership of health insurance in the hands of individuals, instead of the employers. Individuals will buy their own insurance, which will be available to all, and which will be available through one-stop shopping via state-run “regional insurance exchanges.” Families will recieve a tax credit of $5700 ($2300 for individuals) to purchase this insurance, and those with low-income would receive further subsidies. Those who do not make an active insurance choice will be automatically enrolled in a private plan paid for by the tax credit.
And finally (finally for this blog post, at least), there is Bob Laszewski’s proposal, the Health Care Affordability model. Laszewski is a noted healthcare blogger and well-respected policy expert, and accordingly, his proposal is being taken quite seriously by some members of Congress. Laszewski is so smart and his proposal is so detailed that one with DrRich’s limited capacity has difficulty getting through the whole thing. But essentially he proposes to have the feds set formal cost-cutting targets which every private health plan must meet. Those who fail to meet these targets will lose their tax advantages (i.e., companies that continue to provide their products will no longer get tax deductions). Clearly, this will provide a strong incentive for insurance companies to meet those cost targets, and healthcare costs will, accordingly, eventually come under control. Lazsewski emphasizes that his proposal is not really a stand-alone plan, but can be attached to any other plan that’s out there. It will simply give insurance companies the added incentives they need to actually cut costs.
Now, DrRich is not opposed to any of these plans. In fact, he rather likes the Wyden plan and the Republican plan, because they both place the consumer in charge of choosing his/her own health insurance, and they provide for better competition among insurance products within the marketplace.
But alas, all of these alternate plans (and any plan that relies on private insurance) are doomed. The reason is simple. As DrRich has pointed out several times in the past, health insurance companies are no longer interested in providing health insurance. You can’t institute a healthcare reform plan that relies on private insurance – no matter how logical and wonderful that plan might otherwise be – when the insurance companies are all desperately seeking an exit strategy.
People, listen up. The health insurance companies just don’t want to play any more.
Private insurance companies have had 15 years of more-or-less unfettered free-reign to institute any efficiencies they want to. They entered the fray in 1994 (after vanquishing with extreme prejudice the Clinton’s attempt at healthcare reform) with great confidence and enthusiasm, cheered on (initially, at least) by the public and by public officials alike. In the ensuing years they’ve tried all kinds of legitimate ideas for reducing healthcare costs, such as managed care, gatekeepers, clinical pathways, disease management programs, pay for performance, wellness programs, medical homes, and even a ruthless consolidation of the industry to achieve “efficiencies of scale.” They’ve also tried sneaky and underhanded ideas for reducing cost, like cherrypicking patients, making specialty care as inconvenient as possible, browbeating PCPs into zombie-like compliance with care directives, refusing to cover expensive-but-effective services, and cancelling the policies of tens of thousands of patients after they get sick, based on trumped-up technicalities. They’ve tried everything short of dispatching teams of Ninjas in the dark of night to slaughter their most expensive subscribers in their beds.
Yet the cost of healthcare continues to skyrocket, entirely unabated. And despite annually increasing their premiums by more than 10%, insurance companies can see that they have no prospect of long-term profitability.
The insurance companies have shot their wad. They are in despair, entirely bereft of ideas. They want out, and they are now working their exit strategies as hard as they can.
The last thing they want is for Congress to adopt the Wyden plan, or the Republican plan, or the Laszewski plan, or any plan that relies on THEM to figure out how to get healthcare costs under control. They regard such a prospect with the same enthusiasm you’d get if you told a battered, shell-shocked WWI doughboy to leap from the trenches one more time, and trudge through bullet and shell, across 200 yards of mud, blood, barbed wire and bodies, to attack that same machine gun nest once again. Somehow they just don’t believe that, this time, the results will be any better.
This is why the insurance companies are “complicit” with the Obama plan. The Obama plan offers them, at worst, a graceful exit strategy that they can break gently to their shareholders, over time. With luck, they may end up with a long-term business as claims processors for a government plan. They may even get one last windfall in profits, from government-supplied insurance premiums for some of those 47 million uninsured. At the very least, the Obama plan won’t expect them to control the cost of American healthcare. Indeed, the Obama plan expects them to be completely incapable of competing with its public insurance option.
The Obama plan will allow the health insurance companies to stay in the relative safety in their trenches, hunker down, and await the armistice. Any alternate reform plan that hopes to be successful will need to offer the insurance industry a deal at least as sweet.
So as the move toward healthcare reform begins to bog down, President Obama still has an ace in the hole: the insurance industry has nowhere else to go. The support Mr. Obama enjoys from that industry is offered not out of mere political expediency, but out of utter necessity. The undying support of the insurance industry will likely make the administration’s healthcare reform plan unstoppable.
DrRich is glad to have been able to ease the administration’s concerns as their hour of darkness approaches.
*This blog post was originally published at The Covert Rationing Blog*
