Making Sense of it all

The rhetoric has reached a point now where we’re beginning to see articles that attempt to summarize or outline the key issues.  In today’s Washington post, Alec Macgillis provides a  cheat sheet which presents, in the first paragraph, the two key issues:  Coverage for the uninsured.  Still quoting the old 47 million figure, tho with unemployment, the current number is certainly higher.  How do we provide healthcare for these people?  And, most important, how do we pay for it. Cost.  Macgillis lists cost control as a way of paying for the uninsured, but there are other issues: “Medicare and Medicaid are badly straining the national budget.”  I think Peter Orzag would use stronger terms and would argue that cost control (“bending the curve”) transcends healthcare reform.  Our total healthcare spending represents 20% of our GDP, more than any other country.  Medicare alone is predicted to crowd out other discretionary spending in the federal budget.
In the same  Washington Post, Fred Hiatt writes about “Three Camps” that really please no one: Cover Everyone, a.k.a. universal access.   Bend the Curve. a.k.a. control costs via demand.  Consumerism.   The idea is that if patients could see how much individual healthcare services cost (and had some skin in the game), they would  make wiser and less expensive choices.
The volume of rhetoric breeds confusion, and that is indeed what some factions want.  Others endorse covering the uninsured but don’t want the cost controls that would be necessary to pay for it.  Look at the last slide in the Washington Post Interactive and ask which of these players/interest groups would benefit from 47 million new paying customers in the healthcare system.   (Answer:  all of them.)
So what’s a poor consumer to do?  Where do you get reliable information to even think about healthcare reform?  The Post provides an index to their coverage, and reading the writing of reporters and pundits can help.  Always ask, tho, what benefit would accrue to this writer or his employer or his interest group by passing the reforms he advocates.  It’s not that advocacy groups are inherently evil, but they do have an agenda, and you need to interpret what they write in view of that agenda.
What about “experts,” the gurus, the oracles?  Surely, if we asked a very wise person, they would know everything and tell us what to do.  But there is a chink in the armor of academia:  smart people don’t always agree.  Yep.  It’s true.  All Supreme Court opinions are not unanimous.  And smart people sometimes make bad decisions.  Still, it’s worth listening to what they have to say.  As a friend of mine once said, “It is a fact that you have an opinion.  That doesn’t mean your opinion is a fact.” Reminds me of some lines from Phyllis McGinley:

“When blithe to argument I come, Though armed with facts, and merry, May Providence protect me from The fool as adversary, Whose mind to him a kingdom is Where reason lacks dominion, Who calls conviction prejudice And prejudice opinion.”

Below, there’s a link to experts, at least to a list of people the Washington Post thinks are experts.  Their list includes–are you ready for this–Newt Gingrich.  Now Newt is a very smart guy, and he has thought a lot about healthcare, so I’m willing to listen to what he says.  But he, like some others in the list, talks in generalities that are so vague that it could be said he supports everything, or nothing.  The entries are short, and all are worth reading.  Nuggets here and there but no magic bullets.  And guess what?  They don’t all agree.  Imagine that.
Want agreement?  Here’s an Op Ed piece in the New York Times by a group from academia who all agree with each other.  That, of course, doesn’t make their opinion a fact.  Their opinion is, however, well developed, well written, and worth reading.
The Dartmouth approach advocates looking at low cost regions of the country where there is good quality healthcare but lower per capita expenditures.  One fallacy of this approach is that their definitions of “quality” have little to do with healthcare.  This is a trap shared by many who cite the high cost of U.S. healthcare but the limited quality of outcomes.  Life expectancy, for example, has almost nothing to do with healthcare and more to do with genes and the environment.
As you read and listen, keep you eye on the prize:  How can we reduce the cost of the healthcare services we provide?
Some links cited above” Fred Hiatt:  Three camps, but few happy campers. 16 Aug09 Macgillis Your Handy Health Care cheat sheet. of “experts” Health-Care Reform 2009.  Index to articles. & Graphs.  Recording.


Still a BAD idea

The current Republican effort (Graham-Cassidy bill) to repeal the ACA is not really different from previous efforts. The New Yorker says Republicans are “Looking to ram through the Graham-Cassidy bill before the American pubic realizes how awful it is.” Time for a whistle-blower. What will this bill do? First, it will roll back the expansion of Medicaid, thus depriving about 14 million Americans of their access to healthcare. Then it would also cut the existing expansion of Medicaid and convert it to a grant program, but with much less money. This will target the lower levels of society, including children in the CHIP program.
The proposed legislation would also:
1. Eliminate the subsidies for purchasing health insurance,
2. Abolish employer and individual mandates (actuarial suicide),
3. Allow insurers to charge more for those with pre-existiing conditions.

The proposed block grants are not nearly enough to balance the lost revenue for states. Cassidy’s own state of LA stands to lose $3.2 billion if the bill passes. For this reason, Governors generally hate it.
The public hates it, because many of them will lose their health insurance.
The AMA an AARP have also come out against it.

Makes you wonder why Republicans still want to do this. The supposed reason is to siphon off money to give as tax breaks to the wealthy.

Narrow Networks

Employers and insurers alike are narrowing choices for patients seeking healthcare. Employers argue that they are seeking more cost effective providers or those that demonstrate better “quality” (undefined). With narrow networks, insurers can get steeper discounts on care, as providers seek to be included in their plans. For the patient, there will be fewer choices when you need care. This can make decisions easier and may give you more leverage if the provider truly values inclusion in the network. However, it may also mean always going to the low cost provider who can’t get any business otherwise. A transparent selection process with objective metrics would go a long way toward easing patient anxiety. We went thru the low-cost provider era with HMOs many years ago, and the results were not good. Providers may be constrained from offering tests or procedures, because that would run their cost-profie up, resulting in exclusion from the network, regardless of any benefit to the patient. It aso erases the patient’s ability to take their business elsewhere–there is no othe rplace. At the moment, cost seems to be the driving force. Stay tuned.

Single Payer

Bernie Sanders has introduced a bill for single payer healthcare, and four other senators have signed on. Ths won’t make it a law, particularly in a Republican Congress, but it does suggest that this will be a Democratic platform issue in the 2020 elections. There’s a lot not to like about single payer systems, even tho almost every other country in the world has one. First, the government owns healthcare. All of it. Who pays the piper calls the tune, and the government will name the music. That means they will also define what sort of healthcare you can get. Many countries set a value on human life and then analyze any new drugs or procedures in therms of years of useful life added. If the new drug costs more than the life-years it provides, it wll not be allowed. Also when times get tough, and the budget must be cut, healthcare is an easy target. Lines get longer.
Still, we have not come up with another way to provide heatlchare for everyone. The primary goal of the Affordable Care Act was to make it possible for everyone to purchase health insurance and hence have access to healthcare. That has sort of worked, but Republican efforts have left millions stranded without access to healthcare.
That means a single payer system may be the only option left. It does work in most other countries, with some appologies. Patients who live with this system come to accept the long lines and restricted services, because they have never known anything different. Also, some systems allow the wealthy to purchase other health insurance or heathcare that the public system wouldn’t allow.
Interesting that Republican efforts to thwart the ACA may push the country into a single payer system funded by the federal government.

Market Concentration

Market Concentration is a new concept for healthcare. It means simply that if you get sick in this area, you have only one place to go for healthcare. One company owns the hospital and all the physician practices in the community. If you want healthcare, you go to them. There are many such communities. In fact, over 90% of the communities in the US could be described in this way. What does it mean? Well, for one thing, prices are higher. It’s a monopoly, and the provider can charge any price they want. There is little or no compettion. Second, the quality of care goes down. The provider (hospital or physician office) no longer has to pay attention to what customers think, patients have no place else to go.
How does this happen? The local communty hospital begins to have financial trouble. There is lots of money to be made in healthcare, but you have to know what you’re doing. At one time, everyone made money without really trying. Those days are gone. Corporate healhcare organizations get lower prices on supples, but they also know how to manage the processes of care to maximize profits. So a corporate entity (or frequently a university hosptal) will offer to purchase the local hospital. The allure is appealing. “Gee, we could have the University of Anywhere running our hospital.” Why would the Univrsity want to do that? Well, to make money, of course. They will make money off your hospital, and they will also use it as a feeder for their specialty clinics at the Gand Mecca in the next town. If someone in your community needs highly speicialized care, that’s where they will go.
Healthcare will become more expensive because of a lack of compeition. Heath insurance will also become more expensive, because insurance companies lack bargaining power in a comunity with a monopoly hospital.
The new monopoly hospital will then begin buying out local physician practices. Eventually, there will be no independent practitioners. Everyone will work in the Medical Office building next to the hospital.
As patients, we cannot affect this process. The US Congress needs to strangthen the rules on competition and antitrust. That seems unlikely to happen, given the mind set of the current administration. Maybe someday

Medical Tourism

Here’s another approach to reducing healthcare costs: Medical Tourism. Have your big operation done overseas. Costs are much lower, enabling you to bring your spouse along for a little vacation while you are recovering from surgery. The surgeons have frequently been trained in the US and are certified by US specialty boards. Some of the hospitals are managed by US companies.

This option appeals most to those without any insurance, because it’s usually the cheapest way to have surgery. If you do have insurance, check to be sure they will pay the bill. Many will, because the costs are lower than any US hospital.

But be careful. This is one of those situations where it goes well when it goes well. Hospitals overseas generally don’t have the same quality control procedures in place. Medical staff are not organized as they are in the US, so if you have a complaint, there may be no one to talk to. In the US, a nurse has a masters degree in nursing. In many countries, a nurse has only a high school diploma.

Still, it’s a viable option if price is important to you. Check out the Medical Tourism web site or show up at their convention in Los Angeles in October.

The CDC has a page about medical tourism, which lists other things to think about and links to other resources. The main reasons for US patients going overseas are cosmetic surgery, dentistry, and heart surgery.

Eye on the Prize

For many years, the two great problems in American healthcare have been ACCESS and COST. Both of these are amenable to broad political solutions, but neither has been solved. The ACA went a long way toward improving access. In this country, access to healthcare requires health insurance. Hospitals and many providers will not accept patients who do not have insurance. Universal expansion of the MEDICAID option would essentially solve this problem, but Republicans are opposed to this. No alternative has been offered, so, in states such as Virginia, millions of citizens go without healthcare. This issue has reached a point where 60% of Americans favor a single payer, government sponsored health insurance system. Healthcare has become a right. There are many drawbacks to government provided healthcare, but no other solution has been offered to provide health insurance to all citizens. MEDICARE for all may be the only alternative.

The high COST of care has not really been addressed. We pay our providers (doctors and hosptials) more than any other country for the same services. In her book, “An American Sickness,” Elisabeth Rosenthal details various scams that providers and manufacturers use to suck money out of the healthcare system. Not all of these schemes are illegal. Just sleazy. And they do make healthcare more expensive.

Atul Gawande has also written about healthcare costs in the New Yorker magazine. In June 2009, he wrote about McAllen, TX, where Medicare spent $15,000 per resident in a town where the average income was was $12,000. This was essentially an abuse of the fee-for-service payment system. Providers found excuses to provide excessive healthcare to patients, which their insurance paid for.

As patients, we are powerless. A National system of healthcare might fix this, but the healthcare-industrial lobby is a powerful foe.

One of the problems that has evolved recently is the evolution of healhcare providers into a series of monopolies. In a lot of communities in the US, the largest employer is the hospital. If an insurance company wants to sell health insurance, it has to bargain with that single provider over prices. A common scenario is for a distant university to buy out a community hospital. Instantly, care becomes more expensive and more plentiful. The hospital expands in size. More tests and procedures are provided to the same population at greater cost.