Below, a guest post by Jim Jaffe, health editor at Centered Politics.com
Jaffe points out, quite rightly, that “rationing” is already part of our health care system. No health care system can—or would want to—make every treatment available to everyone who might want it. This is not just because of cost. The government also tries to protect us against treatments that would harm us, quacks and snake oil salesmen.
Obama’s health care plan, in particular, is focused on figuring out which services and products are effective for particular patients. Insofar as it “rations” care, it strives to limit the amount of ineffective care that patients receive, knowing that, by definition, ineffective care exposes patients to risk without benefit .
Feared Health Rationing Is Already Here
We’ve barely started to discuss the specifics of health insurance reform and already confront a debate among the deaf. Consider the concerns of the Washington Times, which opines:
“Nationalized health care puts bureaucrats – not doctors – in charge of deciding who needs what medical treatment. Rationing is inevitable under these schemes. That's one reason Mr. Obama's universal health care plans must be stopped.”
The Washington Times makes a strong argument that merits a response beyond an acknowledgement that a bureaucrat can also be a doctor or that rationing exists today. No American who isn’t rich enough to pay the estate tax is now exempt from such rationing decisions, whether they are made by bureaucrats who work for the government, insurers or employers.
It is also an ignorant or audacious argument, because it fails to acknowledge that America’s largest and most successful health insurance program – Medicare – has operated under those rules for years. The population living under such rules is even larger when Medicaid is considered. Such rules are the norm.
The fact is that reformers are merely talking about tweaking rules that already exist, making them a bit more transparent and perhaps somewhat fairer. The inability of either side to acknowledge that this is ultimately only a marginal adjustment of the status quo is creating yet another debate that is basically misleading and needlessly polarizing.
Take bariatric surgery, which controls obesity and is becoming increasingly popular. Only some Medicare beneficiaries are eligible for it, and only then if it is done at selected facilities. If you’re a Medicare beneficiary who’s only 20 pounds overweight and think it would be helpful to have this surgery done at your local community hospital, Medicare won’t pay. The rules are public. Earlier this month, another such National Coverage Determination defined situations when Medicare would pay for a PET scan for a cancer patient.
I certainly don’t have the expertise to applaud or challenge such decisions, but think it important to acknowledge that we’ve been living with them for years. Deciding what’s covered when and for whom may strike some as a bad idea, but it is a pillar of today’s system, not a half-baked scheme by some dreamy socialists who want to redefine the American dream.
Fear mongering ramping up toward an inevitable deafening roar. How long until big bad HMO comparisons start hitting the talking points – “look out, Grandma won’t be getting the care she deserves if some clerk says no”. Like anything else, sound bites carry, and details matter little to a public with diminishing attention spans.
I don’t object to rationing within reason– but I sure as heck object to rationing by ability to pay.
As I see it, opponents of the public option and/or expansion of Medicare, are trying to frighten voters by saying that government bueaucrats might replace the private for-profit insurers who now influence many treatment decisions.
Reform advocates have made it clear that we want a system directed by qualified boards made up of clinicians, scientists and objective (i.e. nonprofit, nonpartisan) health care administrators. I’ve never sat in on a meeting of the oversight boards in France or Canada, but I would like to think that the directors (a) adhere to the hippocratic oath, (b) evaluate the research, (c) conduct a cost benefit analysis with patient outcomes in mind, and (d) apply the reasonable man/woman argument one finds in the field of jurisprudence.
Health care rationing exists in private insurance programs, in public programs, and, as Harriette Seiler says, through ability to pay.
What we need most is not rationed health care, but rational health care. Obama gets that, as his latest interview with the NYTimes shows.
Without rational health care that controls costs by considering efficacy and reasonable choices we will soon have no health care, or health care rationed by cost, for most Americans, since the high cost of health care and the high rate of growth of health care costs is not sustainable.
We need to desensitize people to the word “rationing” or find another word.
Yet ethical and compassionate rationing, especially at the end of life, is the MOST IMPORTANT issue around which the US medical professsion and our young nation can actually mature.
But the word itself remains completely untouchable to most politicians.
Dr. Rick Lippin
Southampton,Pa
It’s unfortunate that the word, rationing, is both explosive and widely misused. To me, health insurance means that I can access a set of covered services in exchange for a premium. Implicitly, services that are harmful or at least clearly not cost-effective should reasonably be excluded from coverage. Suppose it were possible to define every potential medical service, test, or procedure in terms of cost per QALY. If I were offered an insurance policy that would pay for any service, test or procedure costing $100K per QALY or less for a set premium, it’s an easy to understand concept. If I were willing to pay a higher premium, I could presumably buy coverage with a higher QALY limit or perhaps even no limit at all. At the same time, suppose I need a kidney transplant which is covered by my insurance but there aren’t enough available kidneys for everyone that needs and could benefit from a transplant. The available organs have to be allocated on some rational and defensible basis. THAT’S RATIONING.
whilst I sympathize with those who’d like a better word than rationing (personally I like prioritizing), the fact is that the forces of darkness prefer to use it. telling folks that it is not rationing is transparently dishonest and thus counterproductive. so we need other arguments. it would be nice if we could say its like salt and you can get too much of a good thing (or a little goes far) but that sidesteps the basic problem that comes when faceless forces deny them something their trusted physician says is needed. ultimately the message here is “your doctor doesn’t know best,” but that won’t work, however true it may be, for a variety of reasons.
The most odious rationing is that which limits care because of cost.
We’ve had that for years. The conservatives plan for health is built on it.
http://www.medicynic.com
Christopher, Charles, Jim, Maggie, et. al.
Although I live in America, every time I speak w/ other (medical and non medical) professionals re various aspects of US healthcare, I always have an eye opening experience. It’s as if the other speakers are from a different planet when it comes to everything from local medical culture to professional relationships to the local standard of care!
I practice in a suburban setting in the central Midwest. I grew up around relatives who were docs in the 70’s. I’ve had both of my parents receive acute and chronic medical care (and end of life care) in the Midwest and the West Coast. My wife and kids receive a variety of medical services. I have had close relatives use inpt and outpt mental health care. In fact, I have utilized the medical system for my own needs.
A summary of my 35 yrs of practical experience in actually using and watching how the system runs: sloppy, messy, inconsistent [but occasionally peppered w/ a few (unpredictable) shining moments].
I am all in favor of EBM, if it is a means (as opposed to an “end”) to the positive changes in the system which I participate in at so many levels.
I’m MUCH MORE in favor of a more general discussion, w/ the general population, by our universities, medical centers, medical governing bodies (not the insurers or drug companies) re setting expectations (evidence based or not)about what “good” medical care (and good health) looks and feels like, “It’s true, a diabetic pt typically needs multiple meds, often begun in rapid succession, in order to meet generally accepted guidelines for control of glucose, blood pressure and lipids.”
Now this type of “grass roots” education helps cut my work load (time convincing my pts that they really dont need antibiotics, brain MRI, lumbar xry; but do need to take more BP meds to avoid end organ problems), leaving me more time to practice even more thoughtful (hopefully evidence based)care.
Yes, it’s more expensive to educate millions of pts than it is hundreds of thousands of doctors; but it’s not an “either-or” proposition. Educate (ie empower) pts w/ general knowledge/principals while discussing nuances of EBM w/ the providers.
Now we are talking synergy! The doc doesnt have to fight the pt (because the pt’s expectations have been set by authoritative sources [who seem to have minimal conflicts of interest/secondary gains by giving out this type of EBM]. Also, the pt keeps the doctor honest, “doc, dont you want to check my feet today because of my diabetes?”
I compare having an inquisitive, well informed pt keeping the doctor sharp and focused to have a medical student keeping that same doc on her toes!
US healthcare has been touted as an industry like no other…relationship based (the family doc), personalized/customized (“Doc, I want you to write a letter…”), scientific (EBM), but also experience based (the “gray haired” doc).
Reality has set in…as a society, we cant have the $175, 000 per yr doc take care of sore throats (see the $70,000 per yr nurse practitioner or go to the $40 retail clinic); nor have docs own their own MRI machines (excessive/inappropriate utilization).
Society and docs are seeing that medical professionals’ status and roles are (rapidly) changing out of necessity, (financial as well as clinical outcomes).
There is a definite rise of status and pay to “physician extenders” and openings to entrepreneurs (yes, to improve effeciencies and profits, ie commoditize).
None of these changes are inherently “bad”, just different, uncomfortable, unknowable (and not what I saw back in the 70’s and not what I signed up for when I went to med school in the 80’s)
Charles
“Give me a wise doctor-short and stout-with warm hands and a warm heart and with a twinkle in his eye- tells me, kindly,it is my time to die”
Dr. Rick Lippin
Southampton,Pa
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To say that Medicare is the most successful insurance program is just flat wrong.
To the contrary, Medicare and its blind payments of Usual and Customary charges are at the very root of what is and has been the basis for runaway costs charged by providers. “Money Driven Medicine”, I believe, points this out.
Doctors, Hospitals and other providers force patients to contractually assign their benefits prior to any treatment being delivered. This is the primary problem in effecting any rational consumer behavior in the consumption of care – which in any other purchasing situation would cause pricing to be at the lowest possible margin.
With Medicare and the advent of Medicare For ALL, insert the government as the payor instead of the insurance company – now doctors, hospitals and providers have unfettered access to payment, in total, from the government. And just like with Medicare, payments, no matter what the charges, will not be withheld by the government to the extent that charges are Usual and Customary – which is in the total control of the providers.
Insureds are happy to get free care from their providers – let the taxpayer cover it. Who cares.
Unions are happy to have a new pool of employees to organize – nurses, hospital employees, even doctors. Why wouldn’t they be for expansion of government health insurance, or health care as it is commonly referred.
Now, with the recent changes in the Senate and with reconciliation assured, we can watch all of this unfold.
“This is the primary problem in effecting any rational consumer behavior in the consumption of care – which in any other purchasing situation would cause pricing to be at the lowest possible margin.”
The primary problem effecting rational consumer behavior in consumption of health care is a lack of information allowing rational choices. In the absence of information, patients cannot and will not make rational choices. Evidence shows over and over that systems that try to induce patients to make health care choices based on financial motives result in poor care because patients do not make appropriate choices. In particular, they tend to avoid relatively inexpensive prevention and early treatment in favor of waiting for more serious illnesses requiring expensive intervention.
Medicare has contributed to runaway health care costs because of being tied to the “reasonable and customary” system, a system put in place by the private insurance industry and copied by Medicare. However, except for a brief period in the 80’s and 90’s when “managed care” lowered costs in private insurance and especially in HMO’s, Medicare has actually been the main driver in holding down costs. Medicare, as any health care administrator will tell you, engages in much more aggressive cost containment than private insurers.
Scott:
You correctly stated that Medicare pays for care, rather than managing care.
Who is Medicare beholden to?
Well, I guess it is a steward for over 300 million Americans.
So, where is the incentive to manage care?
I have been reading recently the House and Senate debates leading up to Social Security.
I wrote earlier that the payroll taxes which “finance” Social Security and Medicare go into the Treasury, just like income taxes, etc.
All the monies in the Treasury’s general fund pay for governmental expenses.
The payroll taxes are not earmarked to pay current beneficiaries of Social Security and Medicare.
Through my reading of the debates, and other material I have collected, I have discovered that the payroll taxes and the appropriations must be separate, for Social Security and Medicare to be constitutional.
Otherwise, the government would be in the insurance business!
Talk about being overleveraged!
Don Levit
“Medicare, as any health care administrator will tell you, engages in much more aggressive cost containment than private insurers.”
Thanks to Pat S. for that comment.
On this topic of “prioritizing” or “rationing” of care and the ethical dilemma involved, President Obama has recently discussed his own process if decision-making (marked by loving consideration) as his grandmother neared the end of her life. It may be easy for the payer to say “no,” but making these decisions is not easy–for providers or families.
Here’s a link to the interview posted on The New Republic’s “Treatment” blog:
http://blogs.tnr.com/tnr/blogs/the_treatment/archive/2009/04/29/obama-starts-a-grown-up-discussion-of-health-care.aspx
Terence, Harriete, Pat S., Dr. Rick, Barry, Jim, Cycedoc, Charles, Pat S. & Erveryone ,Scott, Harriette
Terence– I am afraid you are right– “sound bites carry” and conservatives have become particularly good at using “bumper-sticker” phrases to carry their message.
These phrases do not aim to stimulate thought–they are meant to close thought.
And unfortuantely, they often contain outright lies like “if some cleak says no.”
Under Medicare, clerks don’t make coverage decisions, physicians and medical researchers make the deicisions based on medical evidence.
President Obama has already appointed a board made up almost entirely of MD’ to oversee comparative effectivenss reserach.
Harriette–
Yes, in the U.S. we ration care according to ability to pay.
In Money-Driven Medicine I tell many stories about patients who weren’t admitted to a hospital for care that the ER recommended because they couldnt’ afford the up-front payment the hopsital demanded.
I also tell of patients turned away from ERs because they don’t have cash or a credit card.
The law now says that an ER can turn a patient away if the patient is sble to walk out the door.
Following this law, two ERs turned away a patieint with a badly broken jaw. He had been jumped and beaten. The jaw was so damaged that he had a hard time speaking and was in terrible pain.
He had proof that he was a U.S. citizen (not that that should matter in an emergency when someone is in that much pain.)
Two ERs turned him away. At the third ER, the doctor who agreed to treat him was aghast. He said that if a surgeon had not taken care of him that night there was the possiblity that the jaw would become infected–which could prove fatal–and at the best, the jaw would have had to be re-broken the next morning before the surgeon could fix it.
The patient paid the doctor, in installments, over a pariod of months.
In countries like hte UK,France and Canada the medical experts who make the decisions have no financial interest in the outcome and in the UK the process is so transparent that NICE holds its hearings in public.
Pat S.–
Yes, what we need is rational care–based on how effective it is. And you are right, President Obama and White House Budget Director Peter Orszag understand th
is.
Orszag wants to assess whether we are getting value for our healthcare dollars based, not on how costly the care is but on how effective it is. (See my response to Barry below.)
Rick–
You are right–we need to find another word.
“Rationing” means to restrict consumption of something (gasoline, food) usually during wartime.
That is not what we are talking about here.
We are talking about
eliminating overtreatment in the form of unncessary, ineffective and often unproven tests, drugs and treatments. We want to squeeze this waste out of the system because it is costly, and because overtreatment is dangerous.
Barry–
We are not talking about refusing to cover some treatments because they are costly.
The UK has to look at cost-effectiveness becaue they have much, much less moeny to spend on healthcare.
Health care reformers in the Obama administration want only to look at “comparative
effectiveness” –and cover the most effective treatment,whatever its cost.
As I have explained before, the bast majority of Americans are not willing to put a price on a year of life. If you continue to talk about Obama’s reform plan in those terms you only add to the misinformation that
conservatives are spreading.
Jim–
You raise a good point about how difficult it can be to explain this to the publc.
It means admitting to the public that in the past, many doctors have been doing things that didn’t help you.
At that point you have to emphasize that doctors didn’t know they weren’t helping you– medical knowledge is constantly changing.
I find that the tonsilectony example helps.
Many people remember when most American children had tonsillectomies (if they don’t remember, they have heardabout it.)
Everyone now agrees that this was unnecessary, and dangerous–some children died as a result of te operation.
And this was twentieth century modern medicin in the 1950s into the 1960s.
More recently, in the 1990s, many breast cancer patients had bone-marrow trasnplants that did them no good and caused untold suffering. They also were very expensive, but that’s not the main point. The point is that the transplant didn’t help and hurt many people. That’s an expamle of the “hazardous waste”]
in our system.
Most of the doctors inovlved were very intelligent and well-intentioned, but the most brilliant doctor cannot look closely at all of the scientific evidence for every treatment that comes down the road.
He has to trust others. And soemtimes the people selling the new treatment or drug are hyping it–over-selling it.
Today, no one doctor can possibly know everything he would like to know about every treatment–even in his own speciaity.
This is why many doctors welcome the idea of having medical reserach that is overseen by an unbiased panel of doctors comparing hte effectivenss of different treatments–and taking a close look at the risks.
In the past, much of that reserach was done by
people who had a financial stake in the outcome. We need to change that.
Doctors would like to see the government gather this information and organizie it in one place, providing “guideliness” for the most effective care for patient who meet a particular medical profile. (This is not one-size-all medicine. Those who claim it is are simply not telling the truth.)
Finally, it is important to understand that, just as in the UK
and other developed countires, these guidelines will not be “rules. Doctors WILL NOT BE REQUIRED TO FOLLOW THEM.
In the UK doctors follow the guidelines about 89% of the time–which is about right. It makes sense that 11 percnet of the time unique circumstances (the fact that the patient is suffering from three other diseases, is simply terrified of surgery, etc.)
would justify deviating from the guidelines.
I realize this is a long explanation, but unlike the bumper stickers conservatives use, it is true.
The truth tends to be more complicated than easy lies.
That’s why it’s hard to
express what Obama is trying to do in bumper-stickers and slogans.
Complicated explantions invite the listener to think–to ask questions. Conservatives who lie don’t want to invite questions.
I don’t mean to suggest that all coservatives lie, They don’t. But Karl Rove conservatives who specialize in fear-mongering and “framing issues” in soundbites do.
Cycedoc– I agree that while the conservatives claim that Obama will ration needed effctive care (which he won’t) their own long-term plan is based on rationing –by income. One level of care for the very rich, another level (or levels) that is “good enough” for the middle-class and the poor.
Charles–
Welcome.(I don’t remember your name or writing voice on this blog before.)
I totally agree that patient education is paramount. That is one reason why I wrote the book, and why I write this blog
And I believe that patient education is a crucial part of health care reform.
You write: “Reality has set in…as a society, we cant have the $175, 000 per yr doc take care of sore throats (see the $70,000 per yr nurse practitioner or go to the $40 retail clinic); nor have docs own their own MRI machines (excessive/inappropriate utilization).
I agree- though I would rather see the patient with a sore throat see the nurse practioner rather than going to the retail clinic (which has an agenda–selling him whatever the retail store sells, and may–or may not–be practicing evidence-based evidence. The patient with a sore throat may get a prescription for antibiotics.)
But I definitely would like to see nurse practioners paid $70,000–or more, depending on the work load–to do many of the things that PCPs do
(or would do if they have time.)
When your parents were practicing, in the 60s and 70s medicine was so very different. The turn came in the early 1980s when healthcae became corporate and “profit driven.” See the final chapters of Paul Starr’s fabulous Pultizer-prize winning book, “The Transformatino of American Medicine. My book, Money-Driven Medicine picks up where he left off.
Now what we need to do is to make medicine “patient-centered” (rather than profit- centered) elimininating the waste that money-driven medicine has created (an MRI unit in every doctor’s office, etc.)
The one thing I would add: while it should be possible to educate your suburban patients, there are a great many poor and pooly educated Americans who need a different approach. They are not able to keep their doctors “on their toes”–these patients need someone to watch out for them and make sure that their doctors are practicing evidence-based medicine.
Scott–
The first private sector insurers agreed to “usual and customary” as the standard– long before Medicare was invented.
Over the past 10 years, Medicare has done a much better job than private insurers in terms of holding health care inflation down.
(Private insurers did a better job in the 1990s when the HMOs were trying to “manage care.”
But the backlash against managed care–by the public, by the media, and by doctors was such that private insurers backed off. By 1999 they decided to cover wahtever Medicare covered and to pay more (typically private insuers pay 10% to 20% more than Medicare pays for the same service.)
Private insurers pass these high costs along int he form of higher premiums.
Finally, this year Medicare will by cutting payments to some providers for some over-priced and not very effective services while raising payment to primary care doctors and others who are now underpaid and provide very valuable preventive care.
The problem is not government health care. The problem is that both the governmetn and private insurers have been over-paying for too much ineffective, unnecessary and over-priced care.
The private insurers are hoping that Medicare will step forward and begin trimming the fat; private insures will follow. They just don’t want to take the blame.
We dont’ yet have a new head of Medicare, but when we do, I’m hopeful he/she will be a very strong person–someone wlling to step up, do the right thing, and explain to the American public why cutting overtreatment is, in fact, in their interest.
It won’t be easy, but it must be done.
Pat S.& Everyone — Yes, this is all true. Everyone: Pat S. is a doctor with long experience who understands
how health care is practiced in the U.S. He
is not an ivory tower academic and he is not a
health policy wonk.
Don–
Medicare has a huge incetnive to manage care.
IF it doesn’t, it will run out of money fairly soon.
Read Peter Orszag’s testimony before Congress on Medicare. Orszag is now White House Budget Director. Watch what happens with Medicare this year.
Harriette– Thanks for the link.
You are right this is a very difficult decision for families and for many providers.
This is why I feel so strongly that we need palliative care teams who are trained to talk about death and to reach out to patients and families and help them make decisions based on the patient’s own priorities.
Pallaitive care teams know how to talk to families that are scared, or feeling guilty, and how to talk to patietts who are getting very very tired, but feel they will disappoint people (doctors, families) if they decide to “let go.”
Tonsilectomies as a routine were elimiatated without the benevolent intervention of big brother. This occured as a result of standard medical practice, which has been, since the time of Osler, evidence based.
I wonder what the rationing board would have said about performing a risky, expensive brain surgery on an elderly alcoholic (senator) with no chance of recovery, after having been turned down for surgery at a well known hospital.
Wait! I forgot, after the great leap forward, such clearly worthless surgery has been eliminated by our benevolent payers. Neurosurgeons, tired of being paid like plumbers, have become plumbers!
Now, there would be no one qualified to perform the operation.
Problem solved.
( However the system evolves, conected people like senators will probably still game the system. )
If reformers really wanted to decrease the volume of operations, looking at the evidence you would think they would advocate for higher fees, since low fees seem to increase volumes.
These are very complicated problems. PET scanning is ordered to solve a problem: it there cancer? So, if you can’t get a PET scan a barrage of less effective, less accurate, potentially more risky, expensive studies will substitute for the scan. The aggregate costs of this work-around is far greater than a PET scan. And this is helpful how?
My guess is the the already bloated administrative stucture of medicine..by far the biggest cost…and curiously not mentioned in reform blogs ..will get even larger, without any discernable effect on costs or waste. There is money for bureaucrats to remind me to vaccinate an ICU patient bleeding to death, but no one to transcribe my operative notes. When does the bureaucratic regulatory mess get attention? When I perform an operation I sign my name on more papers than I did when I closed on my house. I can hardly wait to see how long this is going to take on an electronic record. Oh, wait, I forgot, my time should be wasted, since I would probably only use my time to perform more risky, possibly un-necessary, ultimately stupid procedures, right?
Opps. I forgot, there is no bad regulation.
Terence, Isn’t the point that grandma won’t get her hip operated on? Isn’t ultimately how we lower costs? This is a patient problem, a society problem…not exactly a doctor problem.
There is a Woody Allen momment here. To paraphrase: Medical care is horrible, and it is not fair that Rich people get more of it than I do.
These are real problems waste and cost..but this is not a real solution. We seem to be slouching toward Medicaid for all. I hope we like it.
Christopher George:
You wrote: “Tonsilectomies as a routine were elimiatated without the benevolent intervention of big brother. This occured as a result of standard medical practice, which has been, since the time of Osler, evidence based.”
This, unfortuately, is untrue.
The idea that we were doing a huge number of unncessary tonsillectomies was first investigated by Dr. Jack Wennberg, who would become the leader of “the Dartmouth Research”
Wennberg noticed an inexplicable geographic variation in the number of tonseillectomies done in various parts of Vermont.
If a child lived in one school district, he was all but certain to have a tonsillectomy; if he lived 15 or 20 miles away, he was much less likely to have a tonsillectomy.
It would turn out at that, as is the case with so much medical care (then and today) this had nothing to do with patient need or medical evidence.
It was all a matter of local custom (doctors in one are were in the habit of doing many tonillectormies) and utitmatley, supply of surgeons (more surgeons equals more tonsillectormies, regardless of patient need.)
When Wennberg first wrote about his findings NO Medial Journal would pubilsh his paper.
Ultimately the science journal, Nature, published it.
There was an outcry–and for a long time Wennberg remained “a voice in the wildnerness.”
The government helped back up his claims that doctors were performing surgeries without any evidence that they would be efficacious.
a 1974 Senate investigation into unnecessary surgery found that “American doctors performed 2.4 million unnecessary operations, causing 11,900 deaths and costing $3.9 billion.”
“In 1982, Robert G. Schneider, M.D., calculated that between 15 and 25% of all surgeries were unnecessary — with that figure rising to 50-60% with some types of operations. In the case of tonsillectomies and hysterectomies, the percentage was as high as 40-80%.”
Routine tonsillectomies were not, as you say, “eliminated as a result of standard medical practice.”
They were to some degree replaced by another invasive procedures– putting tubes in childrens’ ears–another unncessary potentially harmful procedure. A rise in the use of ear tubes directly correlates with fewer tonsillectomies.
(In other words, doctors had found another way to
may money on ear, nose and throat infectoins, and eventually bad publicity about tonsillectomies–including the deaths of many children– made the public wary.
IF government had had the power to intervene sooner — producing guidelines that showed how rarely tonsillectomies were effective– many childrens’ lives could have been saved.
Let me answer your diatribe against regulation with one sentence: In countries where there is more regulation of healthcare (all other developed countires) both outcomes and patient satisfiaction are much higher.
Maggie says –In countries where there is more regulation of healthcare (all other developed countires) both outcomes and patient satisfiaction are much higher– and I’m sure that’s true.
That suggests two further questions. First is whether patients are more satisfied in these other countries than before the greater regulation was imposed. Second, particularly appropriate within this conversation, is whether providers are more satisfied.
Maggie,
Tirade? You are hurting my feelings. Your side has won. We are headed for the brave new world which you advocate.
Don’t be a sore winner.
I don’t see the hand of Big Brother in your narrative. What you have outlined is the usual situation when orthodoxy is replaced. Many old ideas have been difficult to discredit over the course of medical history.
I don’t make all my decisions based on money, and I assume others feel the same way.
The doctor who advanced the theory that gastric ulcers are an infectious disease also had trouble getting his work published, but no one benefited one way or the other from this theory.
As I have previously discussed, lumpectomy as a replacement for disfiguring radical surgery for breast cancer was resisted by the medical establishment. Minimally invasive diagnosis of breast cancer had a similar history. Had “expert panels” been in place to quash these advances, I am certain they would have. I am sure that an expert panel would have found gamma knife radiation treatment more cost effective than surgery for Sen. Kennedy.
I was trying to give an example of an ineffective procedure which disappeared without a fight and without the heavy hand of government. If you don’t like the ENT example, how about one from orthopedic surgery? Before WWII, the most common orthopedic operation was fusion of the sacro-iliac joint to relieve back pain. It doesn’t work, except as a placebo. It is essentially never performed today.
In regard to regulation, I am only trying to point out that it has not succeeded in reducing utilization, or eliminating silly tests and treatments. It is very expensive both in terms of dollars and time. Is it worth the cost?
When ineffective medical treatments are discovered, they are generally rooted out. (Not without tears, sometimes, as you point out.) This is not true of ineffective regulatory ideas.
To do a simple biopsy, I spend more time signing my name 8 times then I do performing the procedure. Ten years ago I signed once. Ten years from now, at this rate, will I sign 64 times? Will this really advance safety? Efficiency counts.
Perhaps I would just like to see an example of a regulatory advance which has operated as advertised.
I would rather see competing guidelines, than a single standard set by experts who miraculously have no one’s interest at heart except what is best for the nation as a whole. It is hard for me to believe that after working in the actually money driven world of finance, where an expert is someone who can get on CNBC for thirty seconds, that your faith in “so called” experts is so strong.
Specialty societies and government officials could present patients with optional programs. Breast, prostate, colon, thyroid and other cancer screening programs could be offered with full disclosure of the risks and benefits.
News flash: the benefits are slightly marginal, unless you are the one who dies of breast cancer. But the costs and risks are also small. Let the patient decide, and pay for his or her choice. If the patient has questions, his doctor could advise.
The funny thing is I am really in agreement with you that our medical care system needs a serious haircut. Personally, I don’t think, as a technical matter, that this top down, “New Man” approach is going to work. I am right next to MA and they are going broke.
As a final thought, if we had a European style system, would we be as happy as they supposedly are? We have a healthcare on demand system where you get extravagant often silly treatment. But, if you need to, you can actually see an actual doctor and get an operation, often if you need it or not. Now we will try a system where eventually you probably won’t see an actual doctor, rather a provider, and you certainly won’t get an operation, whether you need it or not.
The irony here is that we are not going to like it once we get this, but I bet it won’t make much difference in the nation’s overall health.
Jim & Christopher George–
Thanks for your comments–
Jim–
By & large, people in other developed countrie give their health care systems much higher ratings than we do. (Most of these countries moved to universal, regulated healthcare sommetime around WW II– we don’t have much polling data before WW II. )
Doctor satisfaction varies.
Primary Care docs in the U.S. are more unhappy than doctors in virutally any other country (terrible working conditions as well as low pay).
Specialists in some other developed countries tend to be unappy about pay–especially when they compare themselevesi to doctors in the U.S. —But you see few of them moving here.
When I was at an international heatlhcare confernce in Berlin last year (a huge confernece, where the vast majority of
participants were from Europe, the UK and Canda,) the consensus was that the U.S. has the most screwed-up health care system in the OECD.
When I asked doctors complaining about lower pay in Europe why they didn’t move to the U.S., the answer tended to be the same: I wouldn’t want to work in that system, and I wouldn’t want my family to get its healthcare in the U.S. system.
Polls shows that people in other developed countries tend to be quite proud of their health care systems when compared to how Americans responding to simiiar polls.
Christopher Geroge–
I very much doubt that I could hurt your feelings (you seem to have a pretty healthy ego)–but if I have, I am genuinely sorry.
You write: “The doctor who advanced the theory that gastric ulcers are an infectious disease also had trouble getting his work published, but no one benefited one way or the other from this theory. ”
But the many doctors who profitdd from surgeries on patients suffering from uclers did benefit from supressing and arguing against the research that showed that this was an infectious disease that coudl be treated withut expensive invasive procedures.
The same thing happend with bone marrow transplants for women suffering form breast cancer. Atter ten years of these useless, very painful and very lucrative treamtns, the Breast Cancer Coalition (a patient advoacy groupd) had to write a letter to all oncologists reminding them that they had a financial stake in this very profitable treatment, adn perhaps they should think about whether this was having an effet on their continued support for the treatment.)
To give credit where it is due– You’re quite right that healthcare regulation hasn’t done what it could or should do.
Perhaps this is because we haven’t had “good governmetn” (an intelligent, effective administration that is able to work with Congress on domestic issues ) for about 44 years.
(in my memory, LBJ is the last effective president who worked for the public good on domestic issues–and succeeded in moving legislation through Congress– Medicare, the war on poverty (the number of poor Americans fell sharply during and after hisadministration–and then rose in the decades that followed) and, of course, Civil Rights legislation.
Chrisotpher- I agree that you and I see eye to eye on many of the biggest problems in healthcare– overtreatment, squandering dollars and putting patients at risk.
But the Massachusetts reform plan bears little resemblance to Obama’s plan. Obama makes contiaining costs his first priority; Mass .made no effort to contain costs.
For this reason, from the beginning, I predicted that the Mass. plan would fail.
Maggie,
I have discussed my pain in Group, and I am healing.
It never occured to me that there was a lobby for ulcer surgery. My experience has been that it is usually scary, touch and go, and usually performed in the middle of the night. Who knew?
We are going to exchange one set of problems which are indeed monumental, for another set of problems which are unknown. Many of the features of reform address problems which for me are not central to my framing of the healthcare crisis.
Coverage, and cost containment should be the heart of reform.
The degradation of the primary care doctor is largely an unintended consequence of the HMO, pre-certification disaster of several decades ago meant to reduce utilization.
This needs to be addressed.
At the time of the HMO inception, specialists thought that the care of specialized diseases was going to be wrested from them and given to family practice doctors with little training in managing these diseases. Neurologists thought that strokes would be managed by the PCPs, leaving them living in cardboard boxes. That didn’t happen. Instead, the PCP was marginalized. It wasn’t the plan at the time, though.
Humbling of specialists seems to be on the reform agenda, which personally or as a matter of policy, is not a good idea. When you need a surgeon, you really need a surgeon.
Herding doctors into large group practices seems to be part of the agenda. This is not required for reform. But as they say in Chicago, a crisis is a terrible thing to waste. Again, I think it is a bad idea. Our University clinic is practically bankrupting the mother ship. Their PCP’s are not well paid, and their patients — largely well off and employed– are virtually guaranteed to need little care get more than they need. The administrative overhead is ferocious. The dirty little secret is that doctors will work much harder for themselves and their patients than they will for a bureaucracy.
Maggie, please note that hospitals buy up medical practices, and not the reverse. The hospital CEO’s and several layers of featherbedding management pay themselves like they are Jack Welsh for running a hotel– badly. If you knew the administrator’s pay and benefits and their contribution you would want neurosurgeons to qualify for food stamps.
Newsflash: the hospitals and clinics take a way way too large bite for administration. This is where I would start. Doctors are the poster children for overpayment, but the truth is slightly different.
Also, the EMR, is not really an essential part of healthcare reform. It really won’t save money. It will reduce productivity dramatically, while the bugs are worked out. The real reason this inchoate half baked idea is being promoted is that the policy wonks, the not-interested-in-actually-practicing-medicine crowd can’t wait to get their hands on the data to further micro-manage medical care. My fear is that this will result in hodge podge of silly incentives which will distract the doctor from the real objective. I also imagine that doctors will be under scrutiny electronically which will make child sex offenders wince.
Personally, I do a fair number of potentially dangerous procedures, which eliminate the need for even more dangerous procedures. I am not overcome with confidence that the quality metrics will realize that my complication rate is low on very difficult cases. (I guess my ego is intact, after all.) Patient selection is going to be very difficult to account for.
Re: BM Tx
I was at the world famous center that pioneered bone marrow transplants in th 80’s, as a lowly medical resident. They are true believers. It took a long time to realize that bone marrow transplantation, which does work for several lethal blood cancers doesn’t for most solid tumors. It would have made perfect sense if lethal irradiation followed by BM transplant would work. Just like it made sense that HMO’s would reduce costs. Neither did work, however.
Like Senator Kennedy most people, patients and doctors alike want a cure. I wouldn’t want to mistake an over developed faith in a particular treatment with a financial motive. (Personally, the quest for fame is just as pernicious in my observation as the quest for money. )
Modern medicine, since WWII, has been a train driven by American medicine. We have many many problems, but clinically — not administratively, obviously — imitation is the sincerest form of flattery. Medicine, at least in Europe and Argentina, where I have been invited to observe, is a much lower stress occupation.
Poverty is a problem in the US. But it is not the problem, for me, that you might think it is. Racism is wretched stain, and a large component. Much of our poor are immigrants, however. Immigrants fleeing desperate poverty for opportunity, here, where they are welcomed and accepted like in no other country in the world. The reason Europe doesn’t have poverty is that they won’t accept poor people. They are turned away at the border.
I like our attitude better.
It does complicate our medical care however.
“Much of our poor are immigrants, however. Immigrants fleeing desperate poverty for opportunity, here, where they are welcomed and accepted like in no other country in the world. The reason Europe doesn’t have poverty is that they won’t accept poor people. They are turned away at the border.”
I think this is an important point that usually gets ignored or downplayed by those who extol what they consider the virtues and superiority of European style socialism and are comfortable with very high taxation required to finance it. I would love to see data showing the percentage of the U.S. population made up of those who have been in the country for, say, less than five years or are here illegally vs. similar statistics for Canada and Western Europe and Japan. Second, I suspect, but don’t know, that we may have a higher percentage of people living in less populated areas than other countries. I would define less populated, for this purpose, as fewer than 50,000 people in the metropolitan area. It is hard to attract doctors to practice in less populated areas because most don’t consider the lifestyle attractive even if they could earn significantly more money after expenses. Finally, regarding our seniors, they do have a pretty good safety net due to Social Security and Medicare and, for the poor, Medicaid. It wouldn’t surprise me if the data show that their medical outcomes are also worse than seniors in other countries, not because they lack insurance or access to a doctor but because they’re more likely to get too much treatment, especially at the end of life at least some of which they don’t even want.
Barry & Christopher George-
Could you provide evidence for some of your assertions?
I really have to object when people use the blog to spread misinformation.
On immigration– Tens of thousands of Africans attempt to make it into Euorope each year.
Many are illegal. In 2006, the Canary Islands became home to some 32,000 illegal African immigrants.
http://www.boston.com/bigpicture/2009/01/african_immigration_to_europe.html.
In the meantime, Europe has welcomed legal immigrants: “In 2004, a total of 140,033 people immigrated to France. Of them, 90,250 were from Africa . . . ”
“Since 2000, Spain has absorbed around four million immigrants, adding 10% to its population. The total immigrant population of the country now exceeds 4.5 million. According to residence permit data for 2005, about 500,000 were Moroccan, another 500,000 were Ecuadorian, 260,000 were Colombian, and more than 200,000 were Romanian. A 2005 regularisation programme increased the legal immigrant population by 700,000 people that year”
While some conservative political parties object to the number of poor immigrants entering Euopre, EU courts have supported the immigrants. For instance ” in July 2008, the European Court prohibited member states from denying residence permits to non-EU spouses of EU citizens or residents.”
Christopher George– a great deal of medical evidence (from Dartmouth and elsewhere) shows that you are simply wrong: multispecialty health centers provide better and more efficient care.
Barry– You write “regarding our seniors, they do have a pretty good safety net due to Social Security and Medicare and, for the poor, Medicaid.”
This is simply not true.
The median income for a single person on Medicare is $20,000, for a couple $27,000. This includes every penny that comes into the house including Social Security, dividends, income from part-time work, food stamps, etc.
As you know “median” means that half of all U.S. seniors live on income that is less than $20,000.
A great many live on $10,000 or $12,000 a year.
If you were living on $12,000 a year, do you think you would fee safe?
Do you realize that a great many people on Medicare can’t use it because they cannot afford the steep co-pays for out-patient care, or the high co-pays for many medications?
“Do you realize that a great many people on Medicare can’t use it because they cannot afford the steep co-pays for out-patient care, or the high co-pays for many medications?”
So, does this mean that Medicare is full of holes and isn’t this the plan that single payer advocates want for the entire population?
I’m told by insurance industry sources that fully 80%-85% of Medicare beneficiaries have at least some coverage to help fill in the gaps in standard Medicare. Over 10 million are in Medicare Advantage plans which often eliminate the need for a Medigap plan. Millions of others either purchase a Medigap policy or receive it from a former employer as part of their retirement benefits. Between 6 and 7 million of the poorest seniors are also eligible for Medicaid (Dual-Eligibles).
Income analysis can be more misleading than ever these days. Since interest rates are now extremely low, it is possible to have over a million dollars invested in a U.S. Treasury Money Fund and receive interest income of less than $20 per month. Many seniors with low incomes have substantial assets beyond a home on which the mortgage is paid off. There are probably a significant number who live with adult children or other relatives and therefore have no housing costs and few other expenses. I know there are seniors who are genuinely poor, but the incidence of poverty in that group compares favorably with the rest of the population, I think. I thought that was one of the main accomplishments of LBJ’s Great Society legislation including the passage of Medicare and Medicaid in 1965.
On a more general level, I want to make a point that is rarely talked about and invite a reaction from you and, perhaps, others. That is, every age cohort has one category of expense that looms large in its budget. For young families, it’s buying and furnishing a home and starting a family. For the middle aged, it’s paying for their children’s education expenses (especially college) while trying to save for retirement. For the elderly, it’s healthcare expenses beyond what is typically covered by insurance. I don’t think it is fair or reasonable for one group (the elderly) to have their big expense item completely socialized when millions of them have significant assets. At the same time, assuming a fully paid for home, fully grown children and no commutation or other job related expenses once they’ve retired, it takes significantly less income to support a comfortable middle class lifestyle than a young family with a mortgage, children to feed and educate and job related expenses needs to generate. I’m all for helping those in genuine need, but I expect the middle class and upper income elderly to pay their way like the rest of us.
Barry–
The average (median) American household now earns about $57,000 a year.
Half earn less than $57,000. Exactly how many of them do you think have “substantial” real esttate holdings or a million dollars invested in a U.S. Treausry Money Fund?
How would they have saved that amount of money and in many cases, raised a family in that pre-tax income? Note that for median-income Americans, wages have not kept up with inflation for the past 25 years.
Your insurance industry friends told you wrong.
As of 2003 only 27% of Medicare beneficiaries had Medigap (Health Affairs).
A larger percenteage (39%) had some supplemental insurance from their employer.
Among poorer Medicare beneficiaries: “only 20 percent of FFS Medicare beneficiaries with incomes below $10,000 had Medigap coverage. Almost 40 percent of FFS Medicare beneficiaries with incomes between $10,000 and $20,000 were Medigap policyholders (Exhibit 1)”
They can’t afford Medigap policies. (The good ones are expensive.) And many cannot afford to use Medicare. .
YOu write: “does this mean that Medicare is full of holes and isn’t this the plan that single payer advocates want for the entire population?”
Barry, I know you read the newspapers. So I know that you know that all health reform plans include subsidies for people who cannot afford them. Subsidies would fill the gaps.
Finally, come back and talk to me about the middle-class “paying their own way” after you, your wife and chld have lived on $48,000 (pre-tax) for a couple of years. ($48,000 would make you part of the statistical middle-class.)
Maggie,
If you add up the seniors who also qualify for Medicaid, the 10-11 million with a Medicare Advantage plan, those who receive supplemental coverage through an employer, and those who purchase a Medigap policy on their own, it could well approach 80% of seniors with at least some coverage beyond standard Medicare.
The subsidies being considered as part of healthcare reform, as I understand it, are intended to help lower income people afford the premium to purchase the insurance policy. I don’t think they also offer assistance with deductibles and co-pays.
As for how much income is required to support a middle class lifestyle, I think living and working in NYC as you do can distort one’s perspective. My wife’s former college roommate is a professor at a small college in rural southwestern Ohio. She tells us that even a young person working at Wal-Mart for nine or ten bucks an hour can afford a decent studio or even a one bedroom apartment in a middle class neighborhood. For families, a brand new 2,500 square foot home can be had for under $200K.
My point about the money fund was that interest rates are close to zero right now. So, if one has $10K or $50K or $100K or $1 million in Treasuries, CD’s or other ultra safe investments, the interest income generated contributes precious little to the household income. Of course I know that most people don’t have $1 million in a money fund. However, most of the children of the Depression lived far more frugal lives than the current generation. My late father-in-law, who died in 1998 and retired as a semi-skilled blue collar worker in 1977, never made more than $10K in any given year. His monthly pension from his employer after over 30 years of work: $128 with no cost of living adjustments. He and his wife, who predeceased him, owned a very modest row house in a working class neighborhood in Philadelphia. After he died, it turned out that they had built over $500K in CD’s and U.S. Savings Bonds. They were not spenders to put it mildly. I think there are lots of people from very modest backgrounds among this generation of retirees whose savings might surprise you even though their current annual cash flow is quite low by the standards of the younger middle class population as well as the income distribution statistics.
Recently my 38 yr totally healthy vegetarian cousin had a small hemorrhoid that was bothering her. Seen her PCP who gave her some cream and was suggested a colonoscopy for follow up and turned out the colono was squeaky clean! By any standard that was a overkill. As mentioned here we need rational and not rationed health care. Why would medicare not spend any resources looking at some random charts in over utilized areas? Once the word is out, rational care follows. I can understand defensive medicine but even that can be prevented and lowered if the reimbursement for counselling patients was better. It is well known that rushed physicians overdo testing and patients who get less face time with physicians sue more as they feel neglected.
Ray–
Good to hear from you.
Yes, your cousin’s experience is typical.
If doctors were paid more for talking to patients–and less for “doing things” to them., U.S. heathcare would be much better.
I understand that colonoscopies can save lives, but, like so many tests, they are overdone.
If you add up the seniors who also qualify for Medicaid, the 10-11 million with a Medicare Advantage plan, those who receive supplemental coverage through an employer, and those who purchase a Medigap policy on their own, it could well approach 80% of seniors with at least some coverage beyond standard Medicare.
The subsidies being considered as part of healthcare reform, as I understand it, are intended to help lower income people afford the premium to purchase the insurance policy. I don’t think they also offer assistance with deductibles and co-pays.