(Photo: Monica Almeida/The New York Times) A hospital in California.President Barack Obama said in his speech to Congress that the nation must address “the crushing cost of health care,” with premiums having grown four times faster than wages in the past eight years and one million more Americans having lost health insurance each of those years. Reform won’t be easy, he said, but it cannot wait another year.
We asked some health care experts, who have seen attempts at comprehensive reform founder over the years, what might make a difference this time.
- Elliott S. Fisher, Dartmouth Medical School
- Kevin Pho, physician
- Daniel Callahan, co-founder of the Hastings Center
- Karen Ignagni, America’s Health Insurance Plans
- Maggie Mahar, health care fellow at the Century Foundation
- Steven Findlay, Consumers Union
Less Spending Can Mean Better Care
Elliott S. Fisher, a professor of medicine, is director of the Center for Health Policy Research at Dartmouth Medical School.
In calling for reform, President Obama emphasized the critical importance of bringing the soaring cost of health care. To do that, we need to address the underlying causes: a fragmented care system; lack of accountability for the overall costs and quality of care; a payment system that rewards growth and unnecessary care.
Our research, documented in the Dartmouth Atlas of Health Care, shows there are remarkable regional variations in spending. Those differences suggest there are substantial opportunities to improve the efficiency of our health care delivery system while reducing costs.
For example, in 2005, per-capita Medicare spending was $10,988 in Los Angeles but $6,838 in Sacramento; $14,360 in Miami, but $7,008 in Tallahassee, Fla.; $12,119 in Manhattan, but $6,556 in Rochester, N.Y.
If higher spending resulted in better care, this data would suggest that we need to spend more. But higher spending regions don’t provide better care. Ten years of research has shown that lower spending regions of the U.S. achieve equal or better health outcomes and quality.
(Photo: Doug Mills/The New York Times) President Obama delivered his first address to a joint session of Congress. The higher spending — and much of the growth in spending — is due to the provision of unneeded and sometimes harmful care: hospitalizations that could have been avoided with better primary care; frivolous specialist consults; overuse of diagnostic tests. Unnecessary care can be harmful because hospitals are dangerous places to be, especially if you don’t need to be there. And having more physicians involved in your care makes it harder to know who is responsible: too many cooks can spoil the soup.
Aligning those varying costs with better health results will take time. The stimulus package, which includes nearly $20 billion to invest in electronic health records, new research programs, and preventive care, will help — especially if the standards for electronic health records are linked to a requirement that all providers within a region adopt them.
President Obama, at least in the speech, was silent on some central issues: whether he would foster the development of a more integrated and organized delivery system, whether he would modify the payment system to encourage improved quality and lower costs, and whether reform will contain performance measures to reassure the public that lower costs are compatible with high quality care. He will have to answer those questions soon.
More Coverage Requires More Doctors
Kevin Pho, a primary care physician in Nashua, N.H. blogs at KevinMD.com.
With the number of the uninsured having risen to 48 million Americans, clearly the need for reform is dire. But President Obama made no mention of who exactly will take care of these patients, even if they get insurance under a successful health reform initiative.
As a primary care physician in southern New Hampshire, I’ve been able to observe a universal coverage experiment, similar to what Congress is likely to consider, taking place in the neighboring Massachusetts.
Since that state’s universal coverage law took effect in 2006, its health care system has been inundated with almost half a million new patients. The demand for medical services has rapidly outpaced the supply of care physicians are able to provide care.
Universal coverage must go hand in hand with the training of more primary care providers — not only doctors, but also nurse practitioners and physician assistants who can provide excellent primary care.
In its most recent annual survey, the Massachusetts Medical Society found that the average wait time for a new patient to see a primary care doctor averaged 50 days. When you consider that this is a state with the highest density of physicians per capita nationally, it is frightening to think what the wait times would be in other parts of the country should universal coverage be enacted on a federal level.
When patients wait that long to see a physician, they inevitably find their way into the emergency department for care that ordinarily can be handled in an office setting. Doing so increases the cost of managing a routine issue up to ten-fold, and indeed, soaring utilization of emergency care has been an unanticipated consequence since reform was passed. In fact, patients who have obtained state-subsidized insurance visit the emergency department at a rate 14 percent higher than the average Massachusetts resident — evidence that lack of access to doctors is a big problem for newly insured patients.
The lesson here is that universal coverage must go hand in hand with the training of more primary care providers — not only doctors, but also nurse practitioners and physician assistants who can provide excellent primary care. According to the Association of American Medical Colleges, there will be a shortage of 46,000 generalist physicians by 2025, a deficit that not only will balloon under any universal care measure, but cannot be made up as both doctors and mid-level providers gravitate toward more lucrative specialty practices.
So, while any attempt at covering the millions of Americans without health insurance is a laudable goal, doing so without addressing a health care system ill-equipped to deal with millions more patients has the potential to make an already grim situation worse.
It Costs More and More to Treat Cancer
Daniel Callahan is the co-founder of the Hastings Center, a nonpartisan research institution dedicated to bioethics and public policy. Currently the center’s director of international programs, Dr. Callahan is author of a forthcoming book, “Taming the Beloved Beast: How Medical Technology Costs Are Destroying our Health Care System.”
No one expected President Obama to spell out a detailed health reform plan in his speech, and he didn’t. But he did say something that, inadvertently, illuminates the difficulty of controlling the escalating cost of care. He said that his administration will seek “a cure for cancer in our time,” and he linked that effort with a large investment in preventive care as “one of the best ways to keep our people healthy and our costs under control.”
The better we do in treating cancer, the higher the costs. Prevention decreases the number of patients while the cost of caring for them increases.
There is a distressing irony in that in that statement: as progress has been made in managing cancer, the costs of caring for cancer patients has steadily risen. President Nixon declared a “war on cancer” in 1970, and that war has advanced on many fronts, but hardly any experts are projecting a near-term cure. Prevention efforts and public education have helped to reduce death rates from cancer (a 13 percent decline since 1990), but prevention appears more successful in improving the quality of life than in lowering costs.
Colorectal cancer reveals what one might think of as the mischievous perversity of medical progress. Despite a decrease in the number of new cases of that cancer each year, the cost of caring for patients with it continues to rise. Many patients who would have died earlier are now kept alive and the cost of their survival and care is expensive. The National Cancer Institute has estimated that the cost of colorectal cancer will increase by 89 percent between 2000 and 2020. That trend will place a particular burden on Medicare as the number of elderly grows. Of cancer in general, the N.C.I. has said that “costs are more likely to increase at the individual level as new, more advanced, and more expensive treatments are adopted as standards of care.”
In short, the better we do in treating cancer, the higher the costs. Prevention decreases the number of patients while the cost of caring for them increases. Can anything be done about such costs? More successful prevention can surely help. But we need to keep in mind the uncomfortable truth that those whose lives are saved from cancer will eventually die (possibly expensively) of some other disease. The health care system will not get off scot-free.
As for the costs of care, pressure can be put on the pharmaceutical and biotechnology industries to hold down the price of their products. Doctors can be paid less for their care of cancer patients. Efforts can be made to persuade physicians and their patients not to undertake expensive treatments with small benefits (or, more harshly, insurance coverage can be denied). The public will have to be convinced that it is not an attack on the value of life to say no to the kind of cure-driven medicine that has brought great benefits but also some nasty ethical dilemmas. President Obama will have his hands full in coming up with a plausible reform that takes account of those mischievous perversities of medical progress.
Set a Cost-Cutting Target
Karen Ignagni is president and chief executive of America’s Health Insurance Plans, a national association representing nearly 1,300 companies providing health insurance.
For the past hundred years, the country has tried and failed to reform health care. Ever since the false start on reform fifteen years ago, political insiders have cautioned against trying it again. But circumstances have changed and now, rather than mobilizing to oppose reform, a wide group of diverse stakeholders — employers, health plans, consumers, doctors and hospitals — is working together to help the nation get to yes.
We’ve learned that we can work together on important issues, like children’s health care, safety net improvement, privacy protection, mental health parity, and genetic nondiscrimination.
We agree that reform needs to address cost, access, and quality simultaneously. There is also broad consensus that we can’t afford to do nothing.
Our organization has put forward a comprehensive plan to bring all Americans into the system. Our proposal urges Congress to set a target of reducing the future growth in health care costs by 30 percent — which would save $500 billion over the next five years. And we support the creation of a public-private advisory group of respected health care experts to develop a policy road map for Congress.
Among the market reforms we would bring to the table is a proposal to guarantee coverage for people with pre-existing medical conditions, in conjunction with an enforceable mandate that individuals keep and maintain health care coverage. By working collaboratively with other stakeholders we can create a uniquely American combination of public and private initiatives that can pass and will work.
Pass It Off to Congress
Maggie Mahar is the health care fellow at the Century Foundation where she writes the blog, Health Beat. She is the author of “Money-Driven Medicine: The Real Reason Health Care Costs So Much.”
Last night in his address before Congress, President Obama talked about the spiraling cost of health care and how it is “one of the fastest-growing parts of our budget.” He emphasized that if we don’t root “out the waste, fraud and abuse” in our Medicare system, the spending on unnecessary and ineffective treatments “that don’t make our seniors any healthier” (but do make those who profit from the system wealthier), we will never bring down our budget deficit.
But greater efficiency will provide only part of the needed funding. I take the president’s emphasis on the deficit as a signal that he does not plan to finance healthcare reform with deficit spending. He leaves the problem of finding the rest of the money to Congress. As the Commonwealth Fund made clear in a report that it issued last week, universal coverage will almost certainly require tax increases.
Root Out Unnecessary Care
Steven Findlay is a senior health care analyst with Consumers Union.
The challenge Obama and Congress face in hammering out health reform legislation centers on financing and timing. Health care spending today (government and non-government) is terribly structured, wasteful, and misappropriated. But that also means that if we do health reform right, we will not have to dig too deeply into the Treasury’s coffers to guarantee that every American has health insurance.
Indeed, it’s entirely feasible that within five to 10 years we can redeploy the projected money we will spend on health care — $2.5 trillion in 2009 rising to $3.1 trillion in 2013 — in ways that cover everyone and improve both access to care and quality of care.
How? There’s an emerging consensus that we must, first and foremost, change the way we pay for care delivered by doctors and hospitals and aggressively root out inappropriate and unnecessary care. There’s less consensus, to be sure, on exactly how to carry out those changes.
On timing, President Obama and Congress will face tough questions on how fast to expand coverage, modify payment systems, and require providers to address long-standing gaps in the quality and safety of care. With many interests at stake, compromises will be needed on these issues. But there should be no compromise on the goal of covering all Americans as quickly as possible, particularly as thousands of families are now losing their jobs and health insurance every week.
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The elephants in the room:
Elephant #1: Most medical spending occurs in the last 6-18 months of life and most is wasted. We’re all read horror stories of invasive tests administered to dying patients. Who’s going to deny extreme but useless end-of-life care?
Elephant #2: Fertility treatments. Sure, everyone has the right to try to have children. But when insurance pays, everyone’s premiums go up.
Elephant #3: Mental health care for the”worried well.” Once you’re functioning at a reasonable level but want “something more,” who should pay?
Countries with centralized single-payer systems don’t allow unlimited use. In fact, they can be quite restrictive. Maybe insurance companies should be, too.
— CatharineHere is part of a message I wrote to David Leonhardt of the Times which gives some of the facts. Somehow these facts must get to the public because actually the health care problem is easy to solve,
My claim is that, in theory, we can solve this problem and provide much better health care for less or the same amount of money for the next 10 or 20 years, at least. The solution is not theoretical; every other wealthy developed country uses it. The theoretical part is whether powerful greedy interests can be overcome to implement it. I also believe that if we adopt a more rational system, it will provide a framework for long term solutions once we solve the dilemma of how much health care do we want. Here is my standard screed on the medium term solution:
I am a mathematician, not an economist, but I have spent some time looking at health care in this country and elsewhere. Forget about the immorality of the uninsured. Disregard the competitive disadvantage of our businesses. Look at health care as a business decision. Suppose you were the CEO of a soulless corporation and you wanted to evaluate some department, the IT department or the health care department. You would develop parameters to see how well the department is doing its job. For health care, these are called public health statistics. You would see how your department was doing in comparison with other similar companies. Then you would compare your cost with their cost.
This has all been done for our health care system. Obviously there is no one way to do this, but the result is so robust (as we mathematicians are wont to say) that it makes scant difference if you vary what countries you use or what public health statistics you use as long as you don’t do a Cato Institute type of analysis where you only look at people making over $10,000,000 a year. The most famous of these analyses was published in the New England J. of Medicine about 15 years ago, but has been brought up-to-date many times. (BTW you can check this and all other figures I use at http://www.pnhp.org.) The author took 12 wealthy countries and the US and ranked them according to 16 public health statistics (life expectancy, infant mortality, etc.). The US ranked last or next to last in every category. No other country was anywhere near as bad. Yet, yet, we spend 2.5 times as much per patient as the average of the other countries. We spend 50% more than the Switzerland which is second in highest cost per patient. In another measure of how well we do, WHO ranks the US 37th in the world in health care. I think that’s above Slovenia, but below Costa Rica.
O.K. we spend much more money for much worse health care. What do the other countries do that we don’t. They have very different systems from pure socialized medicine to a national insurance scheme like Medicare. The one thing they have in common is that they are all single payer systems. There is one entity that makes the rules and does it in the interest of efficiency and helping people stay well and treating them when they are sick. Under our system, there are 1,500 different insurance plans with different rules and forms run by companies whose goal is not to be efficient or give good care, but simply to make money for their stockholders. If a complicated form cuts down on the money it has to give to physicians, and it can make more money even after processing the form, the company will adopt such a form even though it significantly increases costs overall by wasting the time of physicians. One of my doctors says her job is filling out forms. She gets paid depending on how well she fills them out. It’s a hard job because there are many different forms, and they are tricky and complicated, but she works hard and thinks she is pretty good at it. She also has a hobby which she loves–the practice of medicine. She would like to do much more of it and hopes if she makes enough money filling out forms, maybe she can practice more medicine.
A conservative estimate says we waste $200,000,000,000 (two hundred Billion) a year on physicians filling out forms that the single payer systems do not spend. Another $100,000,000 000 is wasted by the overhead of private insurance companies. This includes their processing of the unnecessary forms, fantastic executive compensation, and profit. The overhead for our private companies averages 15% (this may be low as it is several years old and the trend is up). The overhead for the public part of Medicare is 2% and the overhead for the entire Canadian system is 1.3%. I do not have the figures for how much we waste on high drug prices, but I do know that Big Pharma spends 11% a year on research, about 19% on profit, and 34% on marketing. We could cut drug prices by a third and not touch the amount spent on research. Here is a simple example that shows what is wrong.
Suppose you had $100 to give out to 10 people. You could give $10 to each person. Alternatively, you could decide to determine who really needs the money. You could develop a set of criteria, investigate to see who meets the criteria, and then give those the money. Say it costs you $50 to develop the rules and investigate, and suppose you decide to take $25 for your work in distributing the funds. Suppose you find only 5 are deserving. That would leave $25, so you could give $5 to each of your deserving folks. We spend much too much money denying medical care.
Perhaps you are going to trot out the horror stories about health care in other countries. It takes 400 years to get a hip replacement in Portugal or something. A lot of these stories are lies. Some are because of special conditions in some countries The real reason for the real problems is simply that other countries do not spend enough money. Can you imagine what our system would look like if we cut spending by 60%? There is, however, a more important point to be made. In spite of all their problems, the bottom line is that the other countries are getting much better results. We have already seen that.
What about choice? I am 70 years old and retired. During my career I had 5 HMO’s and 5 indemnity health plans. I have much more freedom of choice under Medicare than I had under any of the private insurance plans. I have no more referrals, no more in plan - out of plan nonsense. As for choice of insurance plan, why would anyone want choice if everyone had a plan that covered everything? In any case, you could still have private insurance for those who can afford it as most European countries still do.
Some say the American people would never put up with a single payer system. But Medicare is such a system which would work much better if everybody had it. We would save so much in the three areas mentioned above that we could cover everyone with no deductibles, no co-pays, and 100% drug coverage and not spend a penny more than we are already spending. In fact, covering everybody for everything would make even the Medicare bureaucracy simpler. And Americans love Medicare
— Leonard CharlapDr. Elliot fails to mention another contributing factor in overutilization of health care resources - the increasing ownership of diagnostic and treatment “infrastructure” (from MRIs and PET scans to specialized surgical centers) by the very physicians who receommend these expensive tests/treatments. In addition, our entire health care system is now geared toward maximizing revenue, rather than maximizing outcomes. It’s much easier to talk an administrator into purchasing expensive new technologies based on revenue streams than based on medical outcomes - and this is equally true in the not-for-profit health systems. Incentives for care need to change, which will require an all-around overhaul of the way healthcare is structured in this country. Given the political clout of medical specialists and hospital systems, it will be a very difficult thing to pull off.
— Jeanne, MDI am always surprised to see the cost of medical education in the US omitted from any conversation on healthcare reform. Of course we need more doctors, but is it right to ask 20-somethings to take on the $250,000+ debt of a medical education, often after a very expensive four year undergraduate degree, and with little guarantee of a salary substantial enough to repay the debt?
Medical education costs need to be streamlined and subsidized by the government if any progress on healthcare is to be made. While the four year liberal arts degree is noble in theory, with the cost of education as it currently stands, it is also a luxury for many doctors in waiting, many who have been certain of their career path from a very young age. Why add a further $50,000 - $150,000 of undergraduate education costs?
In the UK, medical education starts after high school and is paid for by the government. In return, fledgling doctors commit to a few years of training with the national health service on a modest but sizeable salary that far exceeds medical residents’ pay in the US. Many choose to stay on with the NHS as GP’s. The result? An entire nation receives decent, primary healthcare at an affordable price, and young doctors are not saddled with mountains of debt.
— Catherine SicilianoMeans-Based Health Care Currency.
There are 7 essential components to this system, which counter-balance each other. Please be patient as you read each one, and then see how the system as a whole works.
1) It uses a high-deductible approach to encourage patients to be value conscious, and to use their first-dollar purchasing power to exert some pressure on providers to be cost sensitive.
2) It uses an intermediary mechanism to enable each patient to pay their deductible and premium based on their means to pay; consumers pay the intermediary mechanism, and the intermediary mechanism then pays the insurance companies and the providers.
3) It keeps insurance companies and providers from “cherry picking” wealthier patients, because they only get paid, by the intermediary mechanism, a price that reflects the national average; at the same time, using this per-capita pricing mechanism, each insurer and provider is free to charge what they want for their insurance products and services. For insurers, both the high-deductible amount and the corresponding premium are priced in terms of a “days wages” for the individual consumer — but the insurance company gets paid the same amount from each consumer based on what the national average “days wages” is. For providers, (doctors, hospitals), etc.. — they too specify their prices in terms of “days wages” — and get paid directly for services that are below a deductible, or by the patients insurance company if they are above the deductible.
4) Insurance companies also provide payment to providers for a patient’s costs that exceed the high-deductible; this helps insurance companies focus on the complex high-cost cases that are too complicated for patients to manage on their own. Thus, the insurance company becomes an advocate for the patient to have providers keep the costs of complex (beyond deductible) care down.
5) The system is also fair across all income levels, because it is linked to a tax-free Health Savings Account, into which consumers can put in about 20 percent of their pre-tax income, and it can accrue in the account tax-free, like an IRA; it can ultimately be rolled over into extended-care living expenses, or into one’s estate, tax free. This encourages everyone to use health services prudently, even at the end of life.
6) It is a relatively incremental approach — all of the existing structures and players remain in place, doing what they do best. It makes it possible to require all insurance companies to accept patients without denying coverage for pre-existing conditions. It can replace employer-paid insurance, which gives patients more flexibility to move and seek better jobs without fear of losing their coverage.
7) It can be automated: a simple Health Card and Account Number is used to pay under-deductible expenses at the point-of-care, and premiums. The apparatus then converts the “days’ wages” stated price, and converts it to what that patient’s corresponding actual amount would be; the apparatus then automatically takes that amount from the patient’s Health Savings Account and pays and Intermediary Central Account; the apparatus then pays the insurance company or provider the price for the service/premium that the insurance/provider had already freely posted as their price for the service/premium, defined as the ‘days’ wages” of the national average income. By being automated in this way, a lot of administrative overhead expenses that are now in insurance and government health care would be eliminated.
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Altogether, what MBHCC accomplishes is empowering patients to use their choice-power to drive medical efficiencies and value — but it does so in a way that remains equitable across all income levels.
Benefits:
>Not government run.
>Coverage is universal, undeniable, and portable.
>Encourages preventative care and healthier life-styles.
>Providers/Insurance Companies remain free to run their business and price their services and products as they see fit — assured to get paid — but get paid based on what the national average income is.
>Uses patient’s value choices to optimize pricing and supply of health care services.
>Equitable across all income levels.
>Provides a means for a person who lives a healthier life-style, and/or makes a choice to forego expensive and often futile end-of-life care, to have that saved money go to advanced age supportive care expenses and to one’s heirs.
Randall Walker
— RandallRochester, Minnesota
all pipedreams. we have guaranteed cradle to grave medical care for every complaint to everyone forever. We cannot afford it. I predict the government will take over to prevent healthcare from devouring the rest of the economy. A line will be drawn in the sand by fiat limiting health care expenditures to a fixed percentage of GNP. After that, it is up to the stakeholders to design the best system with the resources they are limited to. Sound grim? It’s better than living in a society where healthcare takes 30% of GDP and the bridges all fall down.
— jonhere is an idea for fixing the health care: appoint Paul Krugman to the health care department. We need for that job an economist with experience in health care problems. No doctors or insiders for that job. The Kansas lady would be a disaster. It is time for Obama to let go with his pals and paybacks.
— murmillusWhat no one here has addressed are the gross inefficiencies and inconsistencies in the administration of medical care. The cost of miscoded, reprocessed and rejected claims over minor technicalities that should be able to be rapidly addressed.
The insurers themselves are the ones most perfidiously responsible in this matter, as there is no accountability, and no consistent standards of enforcement regarding their perfomance in delivery of services.
There are no incentives to get the claims right the first time, and the focus is on finding reasons to deny claims, when the focus should be on how do we facilitate getting claims processed and paid quickly?
Inefficient healthcare admiistration, and healthcare insurers and pharmaceutical companies need to be held to a higher ethical standard that brings them in line with the physician’s hippocratic oath (with enforceable and significant legal consequences for failure to comply), i.e., to “heal the sick” and to “do no harm”.
Insurance is supposed to be about distributed risk management, but medical insurers refuse to take any risks. They would rather have nothing but strong, young healthy people to cover. Then they could keep premiums low, because they’d be paying out very little in benefits. With this model, who even needs health insurance, if their implicit purpose is to conspire on how not to pay or provide coverage in order to maximize their revenues?
— Bob SzekelyThis is the beginning of our publicly recognizing the increases in trained healthcare providers that must accompany both the improvement and the enlargement of our health systems to adequately cover all Americans.
Along with more health care employees, additional infrastructure will be needed, including some re-deployment from over served areas to underserved locations.
Larry
— Lawrence MyersThe only problem with the current system is cost. Quality is important, but isn’t the problem. The problem is hospitals charge too much. Thats it. They’re accountable to no one. Why should scoping a knee cost as much as a new car? Attorney’s fees? Come on. Hospitals charge that much becasue they can. I hate to say it but everybody (citizens, tourists, guests) deserves Part A coverage. The rest should remain private/competitive. Carries are set up to provide coverage so lets use them. Start an enrollment process tomorrow, they pay the premium, but its a tax credit (their refund is bigger. Stimulus!).
— DanHow do we pay for this? Federal Sales tax. We’re all busy so lets keep it simple.
Why don’t you look at all the other nations that already have national health care systems, and ask what we need to do to improve on all these model systems???
— Jennifer MacAdamThere are six immediate changes that would bring America up to the level and quality of health care delivered in the finest countries on earth
1. Eliminate health insurance - cost to provide it is 52% of cost to deliver health care
2. Eliminate prescriptions for non-controlled (abusable drugs) - cost to provide prescription for things like diaphragms and birth control pills about 15% of cost to deliver health care
3. Eliminate medical records except for original clinical entries provided in a plain paper bound book maintained by the patient - cost to provide computerized medical records to about everyone to everyone about 18% of the health care dollar.
4. Provide up to 70% of the remaining health care dollar (total savings of which is about 82%) to all other health care providers to provide all health care to everyone.
5 Give the remaining 30% left over to the government to be applied to tax breaks for those who earn less than $49,000.00 per year.
6 Freely charge for prescriptions if people want them when they are not required for health care.
Freely charge for the second and other copies of medical records provided for any one other than the patient, but require that only the patient maintains the original.
Freely provide health insurance as long as it is not accepted by providers for required medical services pad by number 4 above.
Use the savings of 15% of the health care dollar saved above give the doctor 15% (double the 7% they receive now) to pay tuition for new doctors and harder work from old ones like me
This is a plan that will work. It is available in almost all other countries than the US today.
Donald Winston, MD
— Donald Winstonwinston@urbansurgeon.com
713-222-1000
713-222.1001 fax
That we require, that those with no insurance coverage, or no ability to pay for care, to enter our health care system, through it’s most expensive delivery area (the emergency room) is absurd.
— Zanger ZunigaDoctors as a rule don’t order unnecessary care unless they have a profit motive (such as avoiding malpractice, or billing for tests from machines they own or lease). Take away incentives to overbill, cut out the middle-men insurance companies and the army of workers that deal with billing on both sides, and things will take care of themselves.
— AntonThe mandatory first step to “fixing” healthcare in the United States is finding out what the expenses are for everyone who is part of the industry. It’s a bit frustrating to see how much is spent yet I can’t find anyone who is “making money”. I become wary of doctors complaining about low reimbursement schedules and then denying care because they “can’t afford to see the patient” because the fee doesn’t cover their three houses, six cars, vacations to Fiji, skiing trips to Courchevel (and don’t forget the alimony payments to the first two wives…) twice per year all while they “work” three days a week.
— They’re not Galen…Is there any analysis going on about how much time health care providers are spending doing paperwork and meeting requirements for insurance providers? Also, what about division of labor- can some functions performed by doctors and nurses be done by specialists who require less formal education and work at cheaper prices? I would be willing to spend less money seeing someone who wasn’t a doctor but skilled at what they were doing.
— scott atkinsWhy do none of these experts mention nationalizing some or all of the the health care industry? It works quite well in Canada, Britain, France, etc. They have universal coverage, well-paid doctors, healthy citizens. US healthcare appears insane and unethical by comparison.
The emphasis of these experts is mainly “rooting out” waste and unnecessary care. That’s like John McCain planning to balance the budget by eliminating earmarks — patently absurd. Removing instead the entire administrative cost of the health insurance industry would go much further.
— GeoffI agree with author Michael Pollan and others: we need a department of food. Obesity, heart disease, diabetes and other chronic conditions would substantially lessen if we ate more locally grown food and fresh vegetables, and less refined carbohydrates. Exercise is preventive, as well as strong social networks.
— Sarah DowsonI am surprised that the Times did not include comments from “experts” regarding the central issue of health care reform: getting the insurance companies out of health care. Many public opinion polls and studies of the views of experts show that there is a growing consensus that health care costs will never be lowered while maintaining quality unless we get rid of the duplicative administrative, management, advertising, and facility costs that come with health insurance and for-profit health care. Add the profit that these businesses make and the problem takes on a strong moral element - why are taxpayers going to subsidize more cost containment for profit-making entities?
— Elizabeth StoryIt’s very clear that the quickest way to bring down health care costs would be to provide community-based diabetes prevention education to the nation’s 54 million prediabetics. The National Institutes of Health spent literal millions upon millions of dollars proving that educating and coaching prediabetics to lose modest amounts of weight and start moderate exercise was twice as powerful as medication in halting their progression to outright diabetes. Despite the fact that these results were published in the New England Journal of Medicine in 2002 we still do not have a coherent program to bring effective diabetes prevention education to communties drowning in this disease. Meanwhile our “medical industrial complex” continues to perform 88,000 diabetes-related foot amputations a year, most of them unnecessary. In sum, while its ok to amputate the feet of low-income people, but not give them the kind of education even NIH says works best, national health insurance or any other “reforms” will be meaningless. Chris Norwood, Executive Director, Health People, the Bronx, NY
— chris norwoodUnnecessary care is easy to define, especially if you’re a cynic. It is care for other people and their families, right? Extreme or end of life care is known to be the costliest — Joe Califano wrote that in the 80s — but who among us is willing to acknowledge that extending a guaranteed-to-end life in its very late stages is excessive for a loved one?
Won’t anyone step up to say eliminating insurance overload — where there were once 65 payers there are now over 1300 — would save money, too?
With the HIPAA system in place to provide the required framework under which physicians and payers communicate, who needs so many payers?
Only the management of those companies. Just how many CFOs of payers are needed? Clearly, a few top-level executives could easily find the economies of scale that they always seek at the claims processor level.
— BarryAs a family practice physician actively exploring a new career outside of medicine I feel that all these solutions talk around a basic societal problem. People want healthcare that is good and cheap. It can be either good or cheap but not both. The true value of any good or service is what people will pay for it, not what they say they will pay. everyone says that their childs health is “priceless” but I have seen many double takes at the price of an MRI or CT and deferrals of such tests. Maybe their “frivolous” but a jury would not think so if a rare brain tumor was missed. The shift needs to be made in a society that does not blink an eye at the annual national carnage on the nations highways of 30,000 deaths a year yet becomes outraged if a patient is dropped off on the curb in skid row and then does not even notice when the offending hospital is closed down. Finally my college classmates who went into finance are making ten times what I make. That finally has sunk in to what my true worth is to society as a physician. It is one tenth or less that of a Wall Street banker. We value money more than health, and until the actual monetary discrepancy is reversed (not the usual clicking of tongues and the rote “That isn’t right” offered as an insincere palliative) it cannot be said that we value health in this country at all. Money talks, everything else can walk.
— DocMattThese experts really don”t say anything specific, much as a cable show host. As a business owner you have to eliminate pre-existing conditions for a start and have some sort of program available for part time workers that don’t meet the hourly coverage threshold. I have two employees I pay premiums for but they can’t get treatment for 1 year as a penalty for their pre-existing condition. This is ridiculous. You try and do the right thing and get penalized by insurance companies. Try not asking “experts” about how to cure the system. Ask regular people what the needs are, from business owners to the intake nurse at an emergency room and see what information you get for a change. That is the disconnect between the government and the media and the people experiencing the problems. Experts don’t have health care problems. We do.
— Bob YoungI was eager to read this post on this critical topic, but am disappointed in the result.
Health care costs more in Los Angeles than in Tennessee? So does a hamburger, a home, electricity. Your point?
Here are some issues I’d like to see discussed if you try again:
> Much of health care costs go to insurance companies’ unnecessary bureaucracy. The percentage of premiums they pay back in benefits is dropping consistently and is perhaps near only 50%. If the plan is to keep insurance companies in the loop, we’re prioritizing the overhead of what are actually stock mutual funds over health care. How can that ever work?
> Rationing Health Care. It looks from Peter Ostertag ex OMB that the Real Obama health care plan is to prevent people deemed to not be “worth” expensive care from getting it (MBA speak: cost-benefit analysis) Need open heart surgery? Better not be too old to be worth it. What you deem “unnecessary” care might save my life.
> Doctors and nurses in the U.S. are paid more than their peers elsewhere, yet we hear that no one wants to be a GP. Why, if we’re paying far more than other countries can’t we produce more, better health care providers? Does the entire medical school hegemony need to be blown up?
> Big Pharma. Why do Americans continue to pay the highest drug costs in the world and why are drug companies allowed to force pharmacies and doctors to charge far more to uninsured patients? Is paying the CEO of a health insurance company $46 Million a big part of the problem?
> Accountability. Life expectancy in the U.S. is now shorter than that in most developed countries. Can we expect a medical system that is delivering inferior results to hold itself accountable? Are we “de-frocking” bad doctors? Closing insurance companies that force bad practices? We can’t have the same people in place doing the same things. If a sports team is losing you get new, better players. We need some new people IMHO.
Thanks perhaps for listening.
— JimFUntil there is nationwide tort reform there will continue to be massively inefficient use of medical resources. So much of what is considered “unnecessary” medical treatment and testing is direct related to practicing defensive medicine…
— j. Cobb