An excellent debate Friday between our very own MA doctor David Himmelstein of Physicians for a National Health Program and Len Nichols of the New America Foundation on the ever-informative Democracy Now.
The physicians group is “a non-profit research and education organization of 15,000 physicians, medical students and health professionals who support single-payer national health insurance,” according to its website. The foundation, according to Wikipedia, “aims to be non-partisan, a goal reflected in the title of The Radical Center: The Future of American Politics, a manifesto published in 2001 by Ted Halstead and Michael Lind. In 2007 Steve Coll, a Pulitzer Prize-winning journalist and former executive editor of The Washington Post, succeeded Ted Halstead as President of the New America Foundation. Well-known board members include political commentator and Newsweek columnist Fareed Zakaria, former Republican governor of New Jersey and former head of the United States Environmental Protection Agency Christine Todd Whitman, conservative philosopher and historian Francis Fukuyama, author and Atlantic Monthly correspondent James Fallows, former Federal Reserve Vice Chairman Roger Ferguson, and liberal economist and professor Laura D’Andrea Tyson. Google’s CEO, Eric Schmidt, is chairman-elect.”
The “Massachusetts model” is discussed at length. It fares poorly.
Nichols, who favors health care reform that keeps private insurance companies in a central position, impressively manages not to come off as completely insane, but is pretty thoroughly trumped on the merits by Dr. Himmelstein, in my opinion. The basis of his argument is that “middle America” is “not ready” for single-payer health care. His sub-text is that the insurance companies have too much political power and will block any solution that does not keep them in business. Many might have made the same “readiness” argument about an African-American president a few years ago.
Check it out and let us know how you score the debate.
peter-porcupine says
You have two people who agree on an outcome, and the debate is implementing it fast or slow.
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p>And the idea that private carriers have to go because of ‘bureaucratic waste’ – which of COURSE cannot exist if government staffs and administers health care – is questionable. Just look at all those efficiencies at MassPort and the Turnpike!
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p>And a personal grump – heaalth insurance, health coverage, and health care are NOT interchangeable terrms.
bob-neer says
Twice as expensive, half as good, and doesn’t serve one-fifth of the population, speaking roughly and in economic terms only, as the system used by every other industrialized country in the world.
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p>Maybe we can move on to the superiorities of the imperial system of measurement compared to the metric system.
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p>Good luck with that.
kbusch says
Am I to understand that something isn’t a debate unless it involves conservatives?
judy-meredith says
This is a debate? (6.00 / 1)
You have two people who agree on an outcome, and the debate is implementing it fast or slow.
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p>and that’s why I gave her a 6
gary says
A: Let’s implement single payer and universal health insurance
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p>B: Let’s not; there are other alternatives, and here’s my idea.
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p>Or,
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p>A: Let’s implement single payer.
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p>B: OK, let’s do that and slowly.
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p>Perhaps each is a debate, but the latter is more like front row tickets to a Kumbaya concert.
kbusch says
In my linked comment, I argue that you conservatives tend to see arguments among liberals as boring, echo chamber stuff. It’s unfun because when we do it we’re not playing with you.
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p>It also seems to me that a lot of the stuff liberals want to do is rather, er, ambitious. Getting it right isn’t easy, it’s pretty hard, it’s rather wonkish.
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p>I’m reminded of how chimpshump’s and JohnD’s diaries can elicit an enormous volume and heat and commentary whereas sifting through policy disappears silently. But Democrats have all kinds of political power now.
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p>We’d better be sifting through policy. We’d better know where we stand. We’d better get down in the weeds.
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p>With power, responsibility.
gary says
The next liberal debate: Obama a great president, or the greatest one. Tune in.
mr-lynne says
Most debates agree on a set of premises at their starting point. That the premises agreed before a debate on an issue among progressives would differ from the agreed premises on an issue debated among progressives and conservatives is not noteworthy in the least. It isn’t the case that this makes the progressive discussion not a debate, merely a debate on different grounds.
gary says
In the debate of medical insurance, I submit the first and most ignored debate is this: is Universal Insurance coverage desireable. That’s the threshold question. Liberal typically jump right to single payer; conservatives jump to the free market. Both ignore the threshold.
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p>I don’t disagree that the current debate, headlined in this thread is still a debate. It’s just a very boring debate.
mr-lynne says
… your assuming that alternatives to the ‘agreed premises’ have not been previously considered. People are allowed, after all, to draw conclusions and then start from those conclusions in further debate.
gary says
I’m just saying the debate referenced in this thread sounds damn boring. Clear enough?
mr-lynne says
… that the first question is ignored. You imply that this is a problem. It’s only a problem if you assume that it hasn’t already been addressed in the past or if there is new evidence that is not being considered.
kbusch says
I’m reminded of what happens to people who live with someone undergoing psychological problems. They’ll tell you over and over again, “He’s crazy!” They’re caught in an endless loop trying to prove it. The “he” often denies being crazy. So they get caught in an unwinnable debate trying to prove to the crazy person that the crazy person is crazy.
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p>They need to move to the next step.
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p>”Okay, he’s crazy. Given that, what are you going to do?”
charley-on-the-mta says
of the Massachusetts law would agree that it is not ideal by any stretch. The fact that Himmelstein thinks so is not exactly news: The single-payer folks are dead-set against private insurance, and against any deal in which private insurers are cut into the deal, much less via a mandate to the public to buy insurance. I have a lot of sympathy with this viewpoint!
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p>The MA law was intended as a politically-possible kludge. It was meant to get people covered. It has done so, remarkably well. It did not, and was not intended, to bite off the other big chunks of health care policy like costs, primary care access, electronic medical records, and so on. These are critical, too! No one involved imagined that passing Chapter 58 would be the end of the line.
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p>But things are now changing. I suspect the political atmosphere is more amenable to single-payer than ever before. That’s not to say it will happen soon — it certainly won’t with this year’s health care push — but if Obama passes a multi-payer universal coverage law that still doesn’t control health care inflation, and in which employers are still on the hook for growing costs, look for big business to get behind single-payer. If that happens, that’s all she wrote.
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p>So I guess that comes as encouragement to Himmelstein et al to keep it up. They’re not influential enough to derail this year’s health care debate; but if the wheels fall off that model, they’ve got the framework for Plan B, and will seem like prophets.
charley-on-the-mta says
I mean to link to this commentary by John Cole, hardly an orthodox leftist:
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bob-neer says
In the context of a resource that we refuse to quantify, as a matter of philosophical approach, in economic terms (not without exception, but in general): life.
kbusch says
Figuring out how to allocate limited resources involves precisely the problem of quantifying things like the value of a human life. It’s unavoidable — or rather it’s only avoidable by making moral decisions in a manner that substitutes irresponsibility for discomfort.
judy-meredith says
And there is no way to get comfortable either.
kbusch says
who has thought about this more than I have and who at least has something to say about it below.
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p>But thank you!
joes says
Let’s say Healthcare is a right of the citizen. Then, we don’t need insurance, it is a given. The only questions are how to manage it and how to pay for it.
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p>Single-payer would have the advantages:
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p>1. Efficiency through economy-of-scale
2. Standardization of treatment and prevention measures
3. Timeliness of innovative treatment being distributed universally
4. Common funding mechanisms
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p>As for the funding mechanisms:
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p>1. Primary funding from a quasi-progressive National Sales tax
2. Secondary funding from affordable individual premiums, scheduled with ability-to-pay
3. Third level funding from affordable individual co-pays, scheduled with ability-to-pay
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p>(The sales tax approach is preferred to employer-paid premiums in that it doesn’t overly burden companies with significant US employment)
lynpb says
For example, the good doctor in the clip in this post asserts that the insurance companies have no incentive to reduce administrative costs. That’s nuts. Insurance companies can profit only to the extent that they can effectively manage their administrative costs. So you see sophisticated automated systems in the insurance industry to enroll members, adjudicate and pay claims, maintain provider networks, detect fraud and manage utilization as efficiently and cost-effectively as possible.
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p>Unless we talk not just about a single-payer model, but about something like a national health service that pays providers a salary and not per procedure, all of those systems and their associated “bureacracy” will still be needed under a hypothetical single-payer national plan – they don’t go away. This is because the systems aren’t necessary because insurance companies are bureaucratic, or even because most insurance companies are for-profit entities – they’re necessary because of the practicalities of paying a fragmented market of health care and health services providers for their work, on a per-visit or per-procedure basis.
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p>Health care providers to me often seem to come at the health care debate from the realms of fantasy: everything would be great if every procedure they would like to order for a patient would be paid for, no questions asked, by a single-payer system. Unfortunately, enough doctors in that scenario would order procedures that haven’t been shown to be effective from motives ranging from ignorance, to the desire to try something to placate a patient, to outright fraud that there would be significant waste. Cost-containment also has to be part of the mix, and that means utilization management and oversight of what providers are getting paid to do for patients.
bean-in-the-burbs says
I forgot to log out my spouse as I do from time to time and posted under her screen name.
kbusch says
nonetheless.
mr-lynne says
… that the costs of administrative overhead is function of scope. As such, the scope of a single payer insurer is less. Less overhead on the administrative costs of marketing and the administrative efforts in denials and adverse selection. (It is presumed that the administrative costs of denials will go down because denials themselves would be reduced – as is evidenced by rates of denial in other single payer systems.)
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p>Your point on providers is well taken. One thing that many progressives are loathe to talk about is rationing. Certainly some form of rationing is a necessary component of cost control. Of course, we already ration,… on the basis of cost and employment.
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p>That being said, there is also a perverse rationing that happens that can save the insurer money, but costs the overall health care system more in the end. This happens because insurers know that they will not carry the patient in their portfolio for their entire lives. Medicare will take over at some point. So insurers are disincentivised to provide the kind of preventative measures or procedures designed to deal with much worse ‘down the road’ complications. In a single payer system, this kind of rationing would be exposed for it’s dollar inefficient nature.
kbusch says
I’m curious. Have there been progressives who have faced this problem? It would seem like just the sort of thing an economist would ponder.
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p>There are also major problems in getting agreements on ethics.
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p>I’d imagine that the Europeans have had to sift through some of this.
mr-lynne says
… Ezra a progressive, then yes.
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p>In most discussions that involve people more interested than casual observers, the subject does come up, especially when a conservative joins the fray. In truth, this isn’t as insurmountable a problem as it seems, all you have to do to start a reasonable discussion is to get everyone to accept the obvious axiom that ‘you can’t have everything’. The discussion often exemplifies the interplay between moral vs. pragmatic. Oftentimes some casual observers become suspicious when the subject comes up, owing to a general disposition of considering the health-care problem a principally moral one. There are certainly moral considerations to contemplate when working out the details. Nevertheless, some system of rationing is an important component of any plan that aims to be dollar efficient. For my part, I suspect that were you to ‘design’ the rationing details in a single payer system, morality and efficacy would largely be in alignment,… especially from the perspective of our current costs.
stomv says
Those are rationed. You can’t legally buy one… you can either
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p>(a) get on the list. Your place on the list is a complex function of how long you’ve been on and how dire your situation is, or
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p>(b) convince someone else to give you their organ.
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p>There’s a limited amount of a resource (kidneys) and they are distributed not by ability to pay, but by need. That’s rationing, and we’ve been doing it for years.
bean-in-the-burbs says
But I question the real promise of this under single-payer.
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p>As I noted above, many of these costs are about paying providers and should not be expected to change in a move to single-payer with other aspects of the healthcare market left unchanged. You mention marketing – would marketing costs go away under a single payer model? Even here, I think likely not. Today, many companies compete to provide the administration of government-payer Medicaid and Medicare plans. (disclosure: I work in IT at one such company). I find it hard to believe that this model would not continue under a hypothetical single-payer arrangement. The companies that compete in this space have made extensive investments that allow them to provide more efficient administration than the states could provide if they attempted to fully run the programs in house. Even with the marketing and sales departments companies like mine maintain to pitch and sell contracts to administer programs, we are still typically more cost effective. It’s hard for me to believe that these companies wouldn’t continue to be successful in selling their services and systems to administer programs.
mr-lynne says
… do you think is necessary under a single payer model? I think if you figured out what was collectively spent on health care insurance marketing, I’d be surprised if a single payer system would need to spend 20% of it. Of course, what a private company would want to pay for marketing their services is a separate issue, since that whole sector would be separate from the single payer system. All the administration going into the negotiation of individual group rates would go poof, as there is only one group. I suppose administration contracts might have some overhead, but most of that would be on the part of the private entity, not the public one (or the service wouldn’t be worth it for them anyway).
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p>Like I said before, it’s really a question of scope and consideration of all the activities that would become superfluous once there was only one insurer in the system.
bean-in-the-burbs says
Due the scope and complexity, will function in practice much as Medicare and Medicaid do today – the government will contract with private industry to administer the program, probably different companies by state and region to leverage existing provider networks, and the companies will pay the providers, much as they do today. I don’t mean to sound cynical; I’m in favor of a national health care plan and universal access. I just think there is a starry-eyed quality to a lot of what I read that doesn’t square with the complexities of managing plans in reality.
mr-lynne says
…, and there’s no indication that your particular brand of future single payer is predestined, the savings from adverse selection by itself is probably worth the transformation. Remember that the primary function of an insurance firm is the management of risk pools. An enormous amount of effort is spent in the management of private pools, because the health of your insurance company and it’s ability to compete in the market is dictated by no single factor more than the quality of the pool. All that effort and it’s associated overhead goes away in a single payer scheme.
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p>Of course, one could arbitrarily legislate adverse selection away without going to single payer, but that would be unfair to the insurer because you’d be taking the primary tools to navigate their own success or failure,.. taking away the ability to manage the most important mechanism to make an insurance business possible.
bean-in-the-burbs says
Most get coverage as part of employer groups that constrain choice but also guarantee the ability to participate – adverse selection is less of a factor than it is in, say, auto insurance, life insurance or homeowners insurance, where identifying and excluding those who are too risky/costly is almost an art form. (Take Progressive’s web comparative auto insurance quotes, for example, where high risk drivers are shown lower quotes from competitors to steer those customers to voluntarily choose NOT to do business with Progressive).
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p>Instead of keeping costs down by excluding sick people from group coverage, what we mostly have been seeing is insurance companies raising health insurance rates to stay ahead of increasing costs.
hrs-kevin says
It is true that insurance companies do have an incentive to minimize the cost of their own administration. However, they have little incentive to minimize the overhead cost to health care providers themselves, in fact, quite the opposite. The fact that health care providers have to deal with the requirements of n different insurers means a lot of extra work and wasted time on their part.
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bean-in-the-burbs says
Heathcare providers, payers and clearinghouses to adopt standard coding and electronic transactions.
bean-in-the-burbs says
So insurers do have an incentive to see providers’ admin costs go down.
hrs-kevin says
Providers have to negotiate with insurers on rates. They don’t get to pass on all of their costs to the insurer. Witness the recent dispute between Tufts providers and Blue Cross.
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hrs-kevin says
judy-meredith says
and gets to the real tough questions on rationing, that everybody else avoids. Props to Mr Lynee, KBush and Bean in the Burbs. What a way to spend a Saturday night.
chrisc says
When one discusses rationing to save healthcare dollars many cringe. When I discuss a patient’s responsibility in managing their healthcare I find myself alone at cocktail parties. Doctors and insurance executives and hospital executives are held to high standards to deliver care above and beyond the publics expectations. I never hear stories about a patient being held accountable for their behavior? Patients can make simples changes in their daily life that will cut healthcare costs and improve outcomes. Incetivizing patients to do so would save millions. Imagine a system that rewards you for stopping smoking? Install treadmill stations in hospitals that document patient’s efforts to lose weight, one hour walk equates to bonus for the patient. These efforts would reduce healthcare expenditures dramatically.
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p>Add patient incentives with honest rationing and you will create a healthcare system that delivers.
mr-lynne says
… has often been talked about in the past as a means of controlling costs. This popularity of this subject is, IMO, a result largely derived by the rise of HMOs in the 90s and the rise of the ‘personal responsibility’ mantra of conservatives during the same period. Indeed, it was often a topic brought up during the reform talks of 93.
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p>For the most part, the gains you’re going to get from incentivising patient behavior are dwarfed by the overall savings you’ll get from general structural reform. As such, the structural reform part of the equation get’s the lion’s share of the discussion.
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p>The other aspect of controlling patient behavior that should be noted is that control mechanisms need not be mechanisms of a health-care system. For example, much has been talked about with regard to obesity and corn subsidies. Nutrition education and labeling also come into play.
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p>If you look at other systems, they often don’t actually do much about patient behavior. I think this is largely because the returns are minimal. The French don’t do much in terms of this subject, other than provide systems that make healthy living easier (day care for example). Britain incentivises doctors on the overall health improvements of their portfolio of patients (and by extension influencing them toward better behaviors), although judging from overall UK health statistics I’m not sure this has resulted in much in terms of cost savings. I suspect that from a ‘bang for your buck’ perspective, this subject is worth considering, but not getting too worked up about. The efficiencies from the risk spread are much more important toward cost savings and probably deserve the lion’s share of the discussion.
chrisc says
I am not picking a fight here, just would like to learn more, where can I find more information about why changing personal behaviors have little impact on health outcome and cost? In my mind, n = 1, I find that my behavior influences my health directly ( eat more fish, cholestrol becomes better, walk one per day, lose some weight, etc etc) Healthcare reform is extremely important to me and i want to know as much as I can about it, if you have any decent sites for me to look at I will, thanks!
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p>For the most part, the gains you’re going to get from incentivising patient behavior are dwarfed by the overall savings you’ll get from general structural reform. As such, the structural reform part of the equation get’s the lion’s share of the discussion.
mr-lynne says
… on the cost savings you’re likely to get from other behaviors or other systems are largely obtained by comparison to other systems and other populations. Based on what we know, the costs we are spending have much more to do with our structure than our overall behavior. I’m not saying that there are not savings to be gained by addressing behavior. I’m saying that this isn’t the most pressing of our cost problems.
chrisc says
A Times article today discussed how healthcare coul dbe improved and determined that patients and their doctors have the majority of the power to improve quality outcome vs any new technology or procedure. Here is an excerpt:
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p>In a 2004 study in The American Journal of Public Health, researchers found that technology played a surprisingly minor role in improving health. In analyzing mortality data from the 1990s, the researchers concluded that only about 1 in 16,000 Americans had their lives extended or saved as a result of recent improvements in health care technology. The real gains in health, experts say, have come from lifestyle changes like smoking cessation and seat-belt use or from public health improvements like vaccination, a cleaner water supply and increasing access to primary care.
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p>The articel states lifestyle changes ( ie smoking cessation, losing weight, etc etc) can make real gains in quality outcomes. I had argued earlier that to acheive better outcomes at a lower cost patietns would need to play a part. I was told that behavior changes would make little or no impact on the cost of care. I disagree, what is the cost impact on someone losing 30lbs over the course of 20 years on say orhtopedic surgery expenses? What if a patient changed their diet before diabetes “turned on”? How much money would be saved on test, blood pressure meds, diabetes meds, other related costs?
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p>I say involve the patient, allow some to benefit financial from their own lifestyle changes and then you will spend less on overall helathcare cost and have happy, healthier patients. Lets face realities, most in the US are motivated by money, lets utilize this behavior to save us all in the end. This is one idea to help make a change. We can walk and chew gum at the same time. I am going out today to find treadmills that provide time stamps on them, I think HMOs would be happy to pay me to incent their members to get of their butts, me included!
mr-lynne says
… with any of the above assertions. Indeed, one of the most disturbing data plots in the last 10 years was a plot that showed little correlation with increased costs vs. outcome of Medicare patients. That we are spending in ways that don’t result in actual benefit seems obvious now from the data. Technology has a lot to do with this.
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p>That being said, if you take the plot of data on cost vs. outcome and assume that the lower bound of cost represents what we should be doing (presumably it includes some good outcome due to changes in ‘lifestyle issues’), the difference between that lower bound and the rest of the aggregate costs still dwarf what I think we’d save through structural changes.
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p>Again, I’m not saying that savings are not there. I’m just approaching this from a ‘bang for the buck’ and ‘first things first’ POV.
chrisc says
I see where you are coming from. I may be off point here but if “bang for your buck” is important, wouldnt rationing be on the top of that list? What is the ROI on bypass for a 95 yr old? I am sure if you considered outcome data you would find they ( the 95 yr old) have a higher death rate from the surgery, I assume their QOL of life would be equal to if not worse than a simialr 95 yr old that didnt need bypass, the surgery most likely would cost between 25K and 50K depending on complications. That is obvious cost savings if you denied the surgery. Studies show the US utilizes more chemo than other countries with same if outcomes ( overall survival – progression free sruvuval may show minor advatages to extra chemo with no overal survival benefit), hospice care would improve QOL for pts deemed to have non-curable metatstatic disease. Hospice utilization is being examined by private pay insurers and medicare, doctors ar ebeing encouraged to discuss hospice earlier, private pay and medicare are “tracking” who uses hospice when and why, they want to know if it oculd be used earlier.
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p>Today i sat in a room with 50 medical providers from one of the most well known hospitals in boston. One doctor who is very well regarded stated he didnt know what procedures/treatment cost? He said they typically bill 3X more than it costs to get back from Medicare what the hospital actually spent ( even thoght he said he doesnt really know his costs). He then said he has to charge a person without health insurance the inflated price of 3X actual cost or he would be charged with defrauding medicare. This anecdote alone tells us we need change in healthcare. What that change looks like or how its implemented is someone elses job. But I always wonder why many jump to conclusion that the govt can manage this complex system, when I need a package to arrive somewher eon-time I dont use the govt system ( US Postal) I use FedEx, US POstal has the scope, the scale, all the infrastructure, but FedEx outpeforms them, would lthis be true with healthcare?
mr-lynne says
… ration, we just do it on price and employment. “…wouldn’t rationing be on the top of that list?” Well, yeah, if you want to consider rationing without consideration of health outcome. The non-correlation of price vs. outcome suggests that we can start rationing on the basis of correlating treatments and likely outcomes. That is to say, the cost-rational choice of treatment should be the one that is most likely to succeed (at least at firt and until it is shown that it didn’t work – then move on to the next most likely and so on).
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p>”Studies show the US utilizes more chemo than other countries with same if outcomes…” I’m aware of those studies and they are in line with what I’ve been describing.
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p>Your points in the first paragraph are well taken. In any rationing scheme, there are choices and decisions to be made on cost vs. outcome. As we’ve discussed above, one real problem on treatment choices has more to do with prescribing treatments that don’t necessarily correlate with better outcomes. The other thing to note is that this has the effect of making our current system of financing medical treatment not very cost-efficient nor ‘outcome’-efficient. In any case, the other problem with financing a system is that specific individual treatment regimens are cost outliers (expensive). The normal way this is supposed to be mitigated is by the spreading of risk, which our current system of private insurance doesn’t (ironically) do very well at all, especially compared to a single payer system. It’s just insult after injury that the outlier expenses might not produce better outcomes anyway.
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p>This is why many health-care reform proposals include some kind of data repository on effectiveness. We just saw this with the drug legislation, but it really needs to be included across the board. This will enable us to start with the most intelligent form of ‘rationing’ – that is ration from what works and don’t ‘wast’ rations on what probably won’t.
joes says
Historically, 22% of a person’s lifetime medical costs are expended in the last 12 months of life.
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mr-lynne says
bean-in-the-burbs says
Folks discussed rationing above, which we can understand as the need to control access to procedures to manage costs.
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p>An approach that may be less fraught is a commitment to evidence-based medicine. The idea here is that access to procedures that have not been shown to be efficacious should be restricted. This can be tough for patients to accept, but it’s part of the package of reforms that could help control costs.
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p>Utilization management should also be employed – monitoring physicians’ prescribing and practice trends, with the goal of identifying outliers that may signal need for physician retraining. Physicians often don’t like this monitoring, but the information that can be gleaned from big data sets is very interesting and key to provision of both better and more cost-effective care. Fraud or poor care can really stick out.