Few observers have commented on how older Americans will fare under the amended Senate health reform legislation, but as things stand, many could be priced out of the health care market. The Senate bill lets insurers in the Exchange charge an elderly person up to three times as much as they would charge a younger customer. Thus many middle-class and upper-middle class Americans in their late 50s or early 60s who don’t have employer-based insurance could find themselves locked out of health care reform.
Under the bill that passed the House, insurers could only double premiums for the elderly. In the past, I had assumed that the House bill would prevail on this point. I also thought that the public plan might be more generous. After all, it would be hard to argue that a government plan that made insurance unaffordable for middle-class, unemployed and self-employed Americans in their late 50s and early 60s was serving the public good. Surely some in Congress would protest, and the public plan would find a way to keep a lid on premiums, probably by incorporating Medicare reforms that lower costs. If private insurers wanted to complete for customers in that 55-64-year old market, they would have to follow suit.
Now, however, it seems unlikely that any major provisions from the House bill will be added to the final legislation. This was part of the deal that the Senate struck with Ben Nelson in order to secure his vote. Meanwhile, the public option is no longer part of the reform bill. As a result, it is quite possible that the comprehensive insurance that older Americans need will be too expensive for many, just as it is in Massachusetts.
Meanwhile commentators such as Ruth Marcus argue that charging elderly customers more makes sense: “older people cost more money to insure than younger Americans — and more than three times as much. Is it fair to require younger people to shoulder all the extra cost?”
But what Marcus doesn’t do is take a hard look at the numbers. Whether or not you think younger Americans should help foot the bill for their elders, the fact is that if this provision stands, the majority of customers in this older cohort simply won’t be able to afford good coverage.
As I noted in an earlier post, households in the 55-64 age group report average joint income of just $55,400. Only 25 percent enjoy joint income over $100,000. In other words, fully one quarter of earn somewhere between $55,400 and $100,000—too much for a couple to qualify for much of a subsidy, too little to able to afford pricey insurance.
Remember, couples earning more than $58,280 will not be eligible for subsidies. A middle-class couple earning $50,000 would receive only a small premium credit. How can they afford to pay three times what a younger person pays? They can’t.
Yet middle-aged Americans need full, comprehensive coverage. A 20-something might feel comfortable with a Bronze plan that covers only 60 percent of the cost of “essential care”—after all, he doesn’t plan to use the insurance very often. But most 60-somethings need to go to doctors regularly to control chronic diseases and address the many problems that come with age. And if they are middle-class, they probably cannot afford to shell out 40% of the charge for each visit to a specialist. Granted, their out-of-pocket payments would be capped at $11,900, but for a household earning just $59,000 before taxes, that’s more than 20 percent of their after-tax income. Even for a couple earning $75,000, $11,900 is a hefty sum. No doubt many would simply put off going to the doctor.
Just how much would a couple have to scrape together to buy a better plan? Judging by prices for Federal Employees’ Plans, a top-of-the line Platinum policy which covers 90% of medical bills is likely to cost a younger couple at least $10,000—probably closer to $12,000 in today’s group market. That means that even if an insurer charged the older couple only twice as much, the premiums would run $20,000-$24,000 annually, rendering insurance unaffordable for both the middle-class and most of the upper-middle-class.
If it seems impossible that a 60-year-old couple earning $59,000 a year would be expected to pay that much, consider this: In Massachusetts, where insurers are allowed to double premiums based on age, a 64-year-old adult living in Boston is asked to shell out between $830 a month and $1,000 a month—or up to $12,000 a year for one person–for a policy with low co-pays and deductibles. For an older couple in Boston, an identical policy runs between $1,740/mo. and $2,000/month.—or $24,000 a year. In the end, everything may turn on what state you live in. States will have an opportunity to protect their older citizens. While the amended version of the legislation sticks with the 3:1 ratio, it adds that if a “qualified health plan is offered in a State with age rating requirements that are lower than 3:1, the State may require that . . . plans comply with the State’s more protective age rating requirements.”
This provision is enormously important, but I am afraid it will only create tension between generations. If insurers are not allowed to triple premiums for older customers, younger customers in that state will wind up paying more. And of course insurers want the younger customers.
Assuming that a state does not shield its older citizens, the legislation offers one alternative: if the cheapest insurance available costs more than 8% of a person’s income, he or she can be exempted from the mandate.
As I have suggested in the past, “universal coverage” that exempts those who cannot afford it takes us back to square one: rationing care based on ability to pay.
The Only Solution: Cut the Cost of Care
The only way insurance will be affordable for many families at the upper end of the middle-class—or for older American–is if the cost of health care itself falls. This means squeezing out the waste; refusing to be gouged by drug-makers; trimming fees for some specialists’ services; and refusing to pay hospitals extra for inefficiencies and errors that lengthen hospital stays and threaten patient safety.
Otherwise, the amount that private insurers pay out in reimbursements to hospitals, doctors and patients will continue to climb by 8% a year, just as they have for the past ten years. And premiums will rise in tandem.
But do you really think private insurers will suddenly get tough when negotiating with drug-makers, device-makers, hospitals and specialists?
Not likely. In order to win market share, insurers need to keep brand-name drugs in their formularies; they want marquee hospitals and popular, brand-name specialists in their networks. This means that they will continue to pay whatever suppliers and providers demand, and hike premiums to cover the costs.
Meanwhile, competition for the well-heeled customers who can afford ever-more expensive insurance will heat up. Insurance companies who cannot attract those customers will drop out of the market, as will middle-class and many upper-middle-class older Americans–unless the government intervenes
As I explained in part 2 of this post, the Senate bill still calls for an Independent Medicare Commission made up of physicians and other medical experts who would oversee Medicare spending—hiking some fees, while reducing others. (Already, Medicare itself has proposed raising reimbursements for primary care by 4% next year, while lowering payments to cardiologists by 6%.)
The Commission would bundle its recommendations in a package, and Congress would have to vote “yea” or “nay” on the entire package within a fairly short period of time. It could not edit the changes. This would protect the Commission from Congressional meddling, and pressure from lobbyists.
Unfortunately, when the Senate’s two health care bills were merged, the Commission lost some of its clout. For example, hospitals were exempted from cost-cutting for ten years. But, as I noted in part 2, Senators Joe Lieberman, Jay Rockefeller and Sheldon Whitehouse have now introduced an amendment that would strengthen the Commission, and let it use financial carrots and sticks to insist that hospitals begin providing better value for Medicare dollars.
Keep an eye on this amendment.
Under the Senate Bill, Medicare Could Pave the Way
There is just one way that private insurers might begin to address the waste in our bloated health care system: if Medicare provides political cover, by cutting costs and simultaneously embarking on a campaign to demonstrate to the public that it is possible to trim spending while lifting the quality of care.
The medical establishment has begun to acknowledge that unnecessary tests can be hazardous to your health. Just this week the Archives of Internal Medicine reported on two new studies estimating that the radiation exposure from the 72 million CT scans ordered in 2007 alone will result in 15,000 additional cancer deaths twenty to thirty years down the road. An editorial in the Archives pointed out that there is an eight-fold difference in CT scan use around the country, with no better outcomes where more scans are done. (For details and some pointed commentary on what needs to be done,see GoozNews)
Around the nation, responsible physicians are conveying this information to patients, medical students, interns and residents. They also are talking about the pros and cons of mammograms. A great many women read past the politically- motivated fear-mongering, and are beginning to ask questions.
This all helps to prepare the public for the upcoming Medicare cuts that will try to wring some of the hazardous waste out of the system. Seniors need to understand that that the goal is to protect patients from unnecessary procedures. No one will be denied needed care. No one will be told that they can’t have a mammogram. No one will be told that Medicare no longer covers CT-scans.
But by lowering the fees that it lays out for CT-scans, Medicare hopes to make the procedure less attractive to physicians who are paid fee-for-service. For example, we know that when doctors lease or buy diagnostic testing equipment and begin using it in their offices, they recommend twice as many tests for their patients. Next year, Medicare plans to reduce reimbursements for these in-office tests.
Mammograms, by contrast, are not terribly expensive. It is unlikely that Medicare—or anyone—would cut fees. But there is “shared-decision-making” legislation under consideration that would pay health care professionals for the time it takes to give patients a full understanding of the risks and benefits of mammograms, as well as other elective tests and treatments. We know that when patients are fully informed, they decide against elective procedures 20 % to 30% of the time.
Meanwhile, doctors like Boston surgeon Atul Gawande are calling attention to the fact that complications following surgery kill more Americans each year than car accidents. Prudent physicians who share decision-making with their patients explain the dangers.
In the film, Money-Driven Medicine, Dr. Jim Weinstein, who spent the first half of his career as an extremely successful orthopedic surgeon, explains that often he just didn’t feel that his patients were “getting a fair shake.”
"When it came to risk," he says, "I knew that many of my patients were thinking, 'I trust my doctor. He is so good that nothing bad will happen to me.' I wanted to say, 'Wait. Stop. This is important. You could die. You could get an infection.'". Ultimately, Weinstein devoted the second half of his career to spear-heading the shared-decision-making movement at Dartmouth.
As care becomes more patient-centered, wise physicians are urging patients to consider their options. Try medication, physical therapy, or change of diet first. Don’t rush into anything. Sometimes back pain disappears. In many cases, outcomes are better for patients diagnosed with early-stage prostate cancer who choose “watchful waiting” rather than radiation. Breast cancer patients who choose lumpectomies over mastectomies are just as likely to survive, though in the worst-case scenarios, they may have to return for additional treatment.
Recently I quoted Dr. Donald Berwick, president of the Institute for Health Care Improvement: “The best health care is the very, very least healthcare that we need. The best hospital bed is empty not full. . . The best CT-scan, the one we don’t need.” This is the lesson that Americans need to learn—as quickly as possible. If they don’t, health care reform will sink under its own weight, wrecked by over-treatment and over-spending.
A few quick points, Maggie.
Regarding your comment, “This means squeezing out the waste”, keep in mind that one man’s ‘waste’ is another man’s income. With regard to the Archives on Internal Medicine article on radiation risk, patients have much more to fear from false positive results than from radiation exposure. Finally, with respect to your comment on CAT scans and fee-for-service medicine, nearly no physician gains financially when a scan is ordered. I agree that many of these scans are unnecessary, but financial gain is not a prime motivator here. See http://www.MDWhistleblower.blogspot.com
Michael–
As I noted, when physicians buy or least the equipment for their offices (and more and more of them are getting CT scanners), they do make the money on the test and reserach shows that they recommend twice as many tests. This is why Medicare is slashing fees on these self-referrals.
Doctors working in hospitals are sometimes encouraged to use the disagnostic equipment so that hospitals can bill for the tests.
The volume of CT scans done in the U.S. has doubled in 7 years. Money undoubedly has something to do with the rise . . .
According to the Annals article, the amount of radiation that a patient is exposed to varies enormously depending on the equipment used and the skill of the person using it.
From what I can gather, in some cases repeated scans could lead to seroius radiation risk. . .
I, personally, would be more worried about false positives leading to further unnecessary procedures.
Of course one man’s “waste” is another man’s income stream. But we can’t expose patients to unnecssary tests just because someone makes money on them.
Some physicians and hospitals will be unhappy; some ox will be gored, but we have to rein in healthcare spending. This is an economic necessity–as Orszag says, we have no choice.
We cannot afford to let the medical industry continue to grow.
And, as the public becomes better-educated, patients are going to be more and more wary of doctors and hospitals that over-treat.
I’ve been following the amended Senate (private insurance bailout) legislation for this particular reason. However, I will be on my own public option (Medicare) by the time this bailout would be implemented. Still don’t know whether I can afford the Medigap coverage though. My mother’s Medigap is going up 10% on January 1st. She can barely cover it. I feel sorry for those behind me. Being charged up to three times as much in a private Exchange. Escaped by the skin of my teeth. I’ll surely remember this when it comes time to vote next fall.
To back up Dr. Kirsch, its not the cost of the scans that is the problem it is their utilization. Mammography centers nationwide are closing because the reimbursement provided is between about $100-150 depending on region and is not sufficient for many places to maintain services unless they are subsidized by other parts of a radiology department.
The main issue as I see it is summarized by the following anecdote:
I recently was on rotation at the West Los Angeles VA where 50 consecutive rule out pulmonary embolism studies were ordered for “shortness of breath.” These are contrast enhanced CT scans of the lung vasculature. Neither the radiologist or the attending that ordered the scans stood to gain anything by these financially. They are both on salary as federal employees. Further, there are strict criteria(Wells Criteria for PE) that should be used by physicians before ordering such a study that places patients into risk groups for having a pulmonary emobolus. Talking with some of the ordering physicians, even lower risk patients by the criteria were scanned because of a physician hunch or “clinical impression.” How should we address these concerns of over-utilization? Should physicians be allowed to follow clinical impressions? Should they be financially forced to follow guidelines? If so will the criteria if used properly protect the physician from the initiation of litigation if the patient later was found to have a PE? These are questions I don’t see being addressed and as a new MD next year, I have to have these answers before “buying in” to the current reforms from a professional standpoint.
When fee for service is added on top of the aforementioned problems, as is seen most blatantly in outpatient settings, clearly there is a conflict of interest that laws like Stark were supposed to address but have failed miserably. This could most easily be addressed by making it illegal for physicians to order patient studies be performed on lab/imaging equipment they have an ownership stake in. IE make it so cardiologists and orthopedists have to send patients to another center if they actually want the echo or MRI. If they order the study someone else collects the technical revenue(no double dipping). If collusion is later found, make it a felony and strip licensure.
Overall my major concern is basically this: As you decrease the incremental cost of these services you will only see higher utilization rates by those who own the equipment. If I own the machine it is not in my interest to keep it silent 12 hours a day, especially if it doesn’t at least pay for itself and some Qualified Radiologist must be willing to accept the professional reimbursement level.
If you really want to reduce radiation exposure, false-positives, contrast nephropathy and other ills of imaging services decreasing the technical component seems to me one of the worst things you can do if enforceable and protected utilization reductions are not included. If you make fees lower, you will increase the utilization as providers/hospitals try to make up for lost income. If you end up going for the jugular and make the reimbursements too low, providing high quality services becomes impossible and the service stops being provided(IE mammo currently in some parts of the country.)
We have to address the ordering physician and have the guts to address utilization. By simply reducing reimbursement, it galvanizes physicians and hospitals against the reform process. It basically states “This year you are worth 8% less than last year, and 10% less than the year before that” and so on. And although you can keep publicly picking on the insurance companies to get reforms started, eventually physician and hospital buy in to any reform will be necessary for it to actually work.
Thanks, Maggie, for your response.
“Of course one man’s “waste” is another man’s income stream. But we can’t expose patients to unnecssary tests just because someone makes money on them.”
Of course, I agree with you on your above comment. My point is that it’s not easy to identify ‘waste’, because the ‘waster’ will not agree with the definition. The physician, device company or medical institution that is committing the waste will argue that it is necessary and legitimate medical care. It will be challenging to cull true waste from the system.
“We cannot afford to let the medical industry continue to grow.”
I agree again. But, which constituency will be willing to sacrifice their interests for the greater good? Physicians? Hospitals? Trial attorneys? Pharmaceuticals? The public? We couldn’t even get the mammogram debacle right a few weeks ago. Health care reform will be a steep climb. http://www.MDWhistleblower.blogspot.com
What a comprehensive, easy to understand post! Thanks for sharing.
I was most intrigued by your analysis regarding states and how they will “protect older people.” It will be no surprise to me that the demographically older states, such as Florida and Arizona, but also Pennsylvania and West Virginia, will end up with political outcomes that best protect the baby boomers. I’d be willing to venture that some of those boomers with adult children in these states would “officially” live with them in order to game the largest advantage.
Thus, Dr. Berwick’s statement, in my humble opinion, is wishful thinking. End user incentivization will be geared toward political pressure to fill beds and take CAT scans. If you have evidence otherwise, I’m happy to hear it.
Once again, great article.
Hi Maggie,
I have a question which may or may not be appropriate for this blog, but I don’t know where else to find the answer. You have mentioned before the possibility of the House just passing the Senate bill intact to avoid risking another cloture vote. But let’s assume the Senate passes their bill by a majority vote this week and the two bills go to conference. Then suppose either some minor changes are made in the Senate bill and Senator Byrd becomes unable to vote, or alternatively some major changes are made from the Senate bill, and some other Democratic senator(s) defect. The next hypothetical cloture vote then fails, killing the compromise bill. Has anything in that process negated the original Senate bill passed in December? Or can the House then as a second effort just pass the original Senate-passed bill and send to the President’s desk? My primary question is legal/constitutional. Less important to me is opinion on whether it would be smart politics.
Chris,Gregory, Michael
Chris–
Welcome, and thanks for your comment.
First we have a very good GAO study showing that when fees for diagnostic tests were lowered sufficiently, utlizization level off.
It didn’t go up as you (and the convention wisdom) suggest that it would.
Some of these tests were so lucrative that the postitive incentive seemed to be drivign growth in volume of tests. Take that away, and physicians just didn’t order as many.
(You’re right, by the way, we pay little for mammograms and mammogram centers have been closing. Given what we know about mammograms, we probably don’t need as many of these centers, but for at-risk women, we should do them and pay adequately for them.)
But when you compare the rates we pay for most test to rates paid in other countries, we are way over-paying for testing.
Keep in mind that our health care has become unaffordable because a) we over-treat and b) pay far more than other developed nations for virtually everything except primary care and nurses (this is after adjusting for differences in cost of living.)
So we need to cut back on over-payment and over-utilization.
No, we don’t want physicians ordering tests based on “impressions.”
In other countries, physicianss adhere to best pracrice guidelines (not rules) much more often (about 88% of the time in the UK.)
In our fragmented system, medical practice varies widely–even among academic medical centers who you would think would be on the same page, using the latest medical evidence available.
They’re not.
Volume of tests done is much, much higher at some medical centers–after adjusting for differences in underlying heatlh of the population –with no better outcomes.
There has been much discussion of letting the comparative effectivenss reserach panel’s guidelines serve as protection for doctors in court. If a doctor followed the guidelines,
it would be much harder to sue him (you’d have to show clear negligence in some other way).
I think this is a good idea; it will be part of one or more of the malpractice pilot studies funded by the reform legislation.
In the state of Washington, it is now very difficult to sue a doctor if he followed the “shared decision-making protocal”–making sure that a patient fully understands risks as well as benefits of elective tests and treatments. (If they go through shared decision-making, 20% to 30% of patients decide against the elective test or treatment.)
There is now federal legislation that would pay health care professoinals for the time it takes to do “shared decison-making” with a patient (co-sponsored by Wyden).
And other states are looking into linking it to malpractice reform.
I agree that self-referral should be illegal. It creates unacceptable conflicts of interest.
You write: as a new MD next year, I have to have these answers before ‘buying in’ to the current reforms from a professional standpoint.”
I’m afraid you are not going to have answers to all of your questions next year.
And from a “professional” standpoint, you have no choice but to do your best to protect your patients from unncessary testing.
As a “Professional,” you put your patients’ interests ahead of your own interests; put yourself at risk, if necessary, for your patients (the docs who stayed with their patients in the hospitals in New Orleans, for example.)
From what you say elsehwere in your comment, I’m pretty sure we agree on this.
But it’s not easy being a doctor these days.
Gregory–
I’m hopeful that once people actually look at the numbers, they’ll have to change the 3:1 ratio.
Howard Dean talked about this on Meet the Press–in Vermont, insurers can charge older people 20% more–not 300% more.
I’m writing about this for the Washington Post Rx section today . . .
Yes, Medigap is getting very expensive.
But really good HMO coverage under Medicare Advantage can be very good (and subsitutes for Medigap). Look for an established Advantage HMO, probably non-profit.
I posted about this– Google it under my name, “established” HMO, MedPAC, “Medicare Advantage.”
Michael–
Some physicians are willing to sacrifice their interests for the greater good. At the end of Dr. ATul Gawande’s latest piece in The New Yorker, he and his colleagues at a Boston hospital are dicussing whether they should go on salary (giving up fee-for service and so no doubt make less than they do now) in order to “bundle” payments.
A great many doctors who have already chosen to join “accountable care organizations” or work for places like Kaiser have already made that choice and are comfortable with it.
There are doctors out there who regularly take Medicaid patients–sacrificing a large chunk of their income–when they could easily fill their appointment book with well-insured patients.
And there are even hospital administrators out there in the vangaurd of those calling for cost control at hospitals (Bob Wachter, for instance. See his blog on my blog roll).
In addition there are
non-profit insurers that are committed to reform. (Geisinger, Community Co-op in the state of Washington, etc.)
I personally know at least one malpractice trial attorney who puts clients’ interest ahead of self-interest.
But I’m most hopeful about physicians and nurses–people who have chosen to go into a profession that is all about helping people.
Anyone who chose medicine as a career sometime in the last 20 years knew that there were much, much easier ways to make money. (Finance, real estate, banking, etc.)
Many of them will step up to put their patients’ interst first.
Of course, this will not be easy. Most people in the health care industry will not volunteer.
Many will have to be dragged kicking and screaming.
But it will happen because we have no choice. We’re getting very close to the wall–a point where healthcare will be unaffordable for the vast majority of Americans.
Chris and Dr. Kirsch are right. Physicians control most of the money spent in the health system. I think previous studies found docs control 80-90 cents of every dollar spent in the system. Moralizing from on high and shouting at docs from the soapbox won’t change how they practice. All it will do is turn them off, create resentment, and guarantee you wait longer for your next appointment.
For big picture cost control, you must take it out of the doc’s hands. The cost of healthcare is an inherently governmental concern. It is a macro concern for politicians to address not a micro concern for physicians to worry about at the bedside. It’s up to politicians to determine how much we should spend on healthcare v. defense v. energy v. foreign aid v. etc… After the healthcare figure is determined (likely 11-12% GDP considering most other industrialized nations spend about that or a little less), the question becomes how best to spread that money around. Bang for the buck if you will. Again, this is an inherently governmental function. Leave it to the elected representatives to determine if it is better for everyone to have primary care or just emergency care. The US rid itself of slavery, defeated fascism, split the atom, and put men on the moon. I’m certain the US will eventually figure this one out. Even though it feels like the biggest challenge in the world right now, the US has faced and handled tougher.
In the meantime, physicians need to get their own house in order and cut down on the mistakes that lead to complications and deaths. We need to stop focusing on the liability and start focusing on the quality of the care we provide. On the micro level, at the bedside, we should be as close to perfect as humanly possible. We don’t need the legal system or the government to tell us we should do our jobs better. Medical Boards have all the power they need to do the job.
Richad, Concerned FP, Michael H
Richard– I’m afraid I don’t know the answer to your question–at least not with certainty.
Someone else??
FP–
I heartily agree when you write: “physicians need to get their own house in order and cut down on the mistakes that lead to complications and deaths. We need to stop focusing on the liability and start focusing on the quality of the care we provide. On the micro level, at the bedside, we should be as close to perfect as humanly possible. We don’t need the legal system or the government to tell us we should do our jobs better. Medical Boards have all the power they need to do the job.”
Yes. But, I’m afraid they have to do more As people like Don Berwick and Atul Gawande (see my post a few days ago with their names in the headlines), we’re gong to have to improve and redesign our health care system from within.
You’re right– physicains drive costs. And they must now husband resources.
They also need to realize that by wasting resrouces they are not just wasting money: they are hurting their patients.
Too many patients are hurt by iatrogenic diseases (inadvertently caused by medical care). Too many are over-diagnosed. Too many undergo unncessary surgery.
I don’t think either Gawande or Berwick are “moralizing from on high” or “shouting.” I hope I’m not.
I realize that some docs will react with resentment to any suggestion that they need to do things differently–or that they may wind up taking a cut in their own income as they move away from fee-for-servcie care that pays them for volume and toward patient-based, accountable care that pays them for qualtiy.
But many doctors have already chosen to work for accountable care organizations, on salary, earning less than many would earn fee-for-service.
Not all physicians are money-driven. I know this.
Others are ambivalent, but if they find mentors and strong leadership within their profession, they would be relieved to be working in a system where the priorities have changed.
IT’s hard to run a patient-centered revolution by yourself. Docs need support from other doctors.
Finallly, on what governmetn can and can’t do. You write:
“Leave it to the elected representatives to determine if it is better for everyone to have primary care or just emergency care.”
Here is what long-time Senator Jay Rockefeller understands about his colleagues:
“If you really want to be honest about it, eight to 10 percent of the members of Congress understand health care. At maximum.
” I chaired the intelligence committee, and health care makes it look like riding on a tricycle it’s so complicated. So what you have is lobbyists picking on congressmen who don’t know health-care reform, and they say, you know what, you could get a lot more jobs in your state if you only put more money into oxygen or a certain medical device. If you’re going to do Medicare right, understanding that the trust fund is going to go downhill in 2016, you can’t have Congress making these decisions. You need professionals.”
And the professionals, I’m afraid are you– physicians, nurses, public heath experts, medical reserachers, hospital administrators who are medical professionals (not just businessmen) and others educated in various aspects of health care.
Most legislators are not at all educated in this area. Many are not well-educated in any area.
Many are not wise.
Sadly, at this point in time, many are just people who are able to raise enough money to run for office, and they are personable enough to win.
Somewhere between 1/3 and 2/3 (I have read both numbers) of our legislators don’t have a passport. They have never left the country.
Some are very well-intenstioned and have very good values.
Some are true political professinals– like Nancy Pelosi. (I have to hand it to her for marshalling the votes. She did an excellent job. But I wouldn’t expect Pelosi to figure out how to redesign our health care system and I don’t think she woudl want to.)
A few are brilliant (though brilliant doesn’t always mean wise.)
A small group possess the expertise needed to even read and understand the MedPac reports.
There was a time when a larger percentage of our Congress were statesmen and stateswoman.
That was before running for office became so very, very expensive. Now it’s about fund-raising. So you have to be very, very wealthy, or very, very good at fund-raising. That narrows the pool.
The pool is further narrowed by general cynicism and suspicions about politicians and the degree to which they are “owned” by lobbyists. Unfortuantely, much (not all) of this cynicism is warranted.
A great many very bright and honest young people wouldn’t ever run for Congress–haven’t even considered it for the last 20 or 30 years.
You write: “The US rid itself of slavery, defeated fascism, split the atom, and put men on the moon. I’m certain the US will eventually figure this one out.”
Congress did not split the atom. A group of scientists figured that out. (Experts)
Congress didn’t put a man on the moon either–experts did that too. Congress did provide the funding, largely because many were obsessed with the Cold War and wanting to beat Russia (thinking that Russia might attack us from outer space–a truly lunatic idea.)
Congress did not “defeat fascism.” Congress was against entering WW II. Many were isolationist.
Congres also was dead-set against taking many Jewish refugees.
Ultimately, we got into the war (thanks to Roosevelt, not Congress, with particular thanks to Eleanor) and our soldiers helped British, Canadian, European and Russian soliders defeat fascism.
Many of those who fought underground in Europe paid the heaviest price in terms of lives lost, and showed extraordinary individual courage.
The British endured seemingly endless bombing at home.
Churchill, along with FDR helped keep morale high, and ordinary citizens pitched in.
If it hadn’t been for the U.K. and the Royal Air Force, the allies couldnt’ have won the war.
Michael H–
Thanks!
I agree some states will be more inclined to protect their older citiziens.
On Meet the Press, Howard Dean pointed out that in Vermont insurers are only allowed to charge older customers 20% more–versus
300% more in the Senate bill!
Reform will, I think create incentives to husband resources.
For instance Medicare is goign to be paying bonsues to hospital/physician groups that provide “value” by producing better outcomes at a lower cost (fewer tests) –called “value-based purchasing.
In some countries (notably Sweden) Hospital CEOs are praised (and perphaps rewarded, not sure) for having empty beds.
IT’s seen as a sign that they are doing a good job of treating patients,that few patients are staying longer because of infections or errors, that they are fewer preventable readmissions.
Berwick has suggested that we might begin paying hosptials something for empty beds–would still be much cheaper than paying them to hospitalize ever patient that comes their way–and much safer for patients.
This is rather like paying farmers not to plant.
Berwick isn’t dreaming. He has been instrumental in helping a great many hospitals become more efficient–better outcomes at a lower cost, using fewer resources.
See his excellent book: Escape Fire.
answer to richard’s query. if House simply passed Senate iteration of bill, which will happen when pigs fly, it would go to wh for presidential signature.
Hi Maggie,
I have to hand it to you. Your debating techniques are excellent. I have haven’t seen those kind of topic changes, mischaracterizations, or strawman arguments since high school debate class.
To get back on topic… the issue of cost control is and should be at the level of our elected leaders, not at the bedside with the doctors. Whatever system our people via their elected leaders decide to create should prevent doctors from having to worry about cost control at the bedside. Macro v. Micro. Docs are highly trained to identify and stamp out disease. That should be their focus.
Again, on a societal level, we should leave it to the elected officials to determine how much money should be in the health care system and how it should be distributed. I’m confident that the US will figure this out.
Richard —
If the House passes the senate bill as is, the voting is done and it goes to the president.
If the conference committee creates a bill different from the Senate bill, the Senate can only vote that bill up or down. It once again requires a 60 vote majority.
If the conference bill fails in the Senate, the bill is dead. The old bill is dead also. The senate could try to pass the old bill again, and could send that once again to the house. I am not clear if it actually has to go back to the various Senate committees to be passed again.
So the short answer is that if the House does not accept the Senate bill as is, and if the Senate does not accept the conference bill as written, the process starts over again, with the possibility that the senate could skip some steps (say go straight to a Leader’s bill without committee input, if the same bill is re-introduced,) but the fact that the bill passed before the conference bill means that it is dead for the time being, with going back to the old bill not allowed.
I already pay for my own health insurance, approx $10,000 per year. I guess that will go up to $20,000 which I simply can’t afford.
So the best option seems to go without, pay whatever fine they assess me and if I ever get really sick, sign up for insurance that can’t deny me due to preexisting condition.
Help me, where am I wrong? This can’t be the net result of reform for me can it? The already insured effectively lose insurance because its too expensive?
I am serious, help me figure this out.
Hard to believe that Dems in Congress would want to lose the support of seniors when voting time rolls around.
Maggie,
Many topics of interest to me in this post:
“Medicare plans to reduce reimbursements for these in-office tests. As I noted, when physicians buy or least the equipment for their offices (and more and more of them are getting CT scanners), they do make the money on the test and reserach shows that they recommend twice as many tests. This is why Medicare is slashing fees on these self-referrals.”
In fact what Medicare is actually doing is slashing fees on outpatient imaging. This includes BOTH self referred tests and NON self referred tests. Initial results have shown a decrease in costs without any reduction in access. Further cuts will most likely reduce access – time will tell. What the government did was a classic example of solving the problem with a sledge hammer rather than a scalpel. If the problem was self-referral as you stated, the problem could have been solved with Stark type self referral laws. Instead the Government just “whacked” the whole sector on the head.
“In other countries, physicians adhere to best practice guidelines (not rules) much more often (about 88% of the time in the UK.)”
I have challenged you for data to back up this assertion twice without a response. My reading in this area suggests that physicians adherence to guidelines is poor in the US AND IT IS ALSO POOR in the UK, Canada and Australia. And of course it depends on which guidelines you are referring to. Every physician who orders mammograms is by definition not in compliance with someone’s guidelines.
Concerned F.P. said: “from a big picture cost control, you must take it out of the doc’s hands. The cost of healthcare is an inherently governmental concern. It is a macro concern for politicians to address not a micro concern for physicians to worry about at the bedside. It’s up to politicians to determine how much we should spend on healthcare v. defense v. energy v. foreign aid v. etc… After the healthcare figure is determined (likely 11-12% GDP considering most other industrialized nations spend about that or a little less), the question becomes how best to spread that money around. Bang for the buck if you will.”
I agree with Concerned F.P. and think he/she stated the problem well. Politicians would love for Physicians to take responsibility for rationing care (which in my opinion needs to be done) – this is what capitation is all about. Making physicians into gatekeepers thrusts them into an ethical dilemma they don’t want to be in. It also subjects them to second guessing and lawsuits. Obviously, Physicians need to be involved in helping guide this process, but any cost benefit decision (which we need to start making) inevitably depends on ethical/moral issues that Physicians are not in the best position to make.
And an off the topic comment: “If it hadn’t been for the U.K. and the Royal Air Force, the allies couldn’t have won the war.”
The real truth is that the war against Germany was won by the Russian Army. For most of WWII the Germans had 3 times as many troops committed to the Eastern Front as they did to the Western Front and suffered 3 times the casualties in the East they did in the West. Imagine how D-Day and the Battle of the Bulge (my dad was in the US Army in the periphery of this Battle) would have gone if the Germans had 4 times as many troops in France as they did. Everything that Britain and the US did to fight Germany would have been irrelevant without the Russians, who lost over 10 Million people.(Compared to US losses of about 500,000 on both fronts.) The war in the Pacific was a different story.
I spend countless hours and keystrokes trying to promote the following two basic messages.
1)More is not always better in healthcare(often it is worse and even harms)
2)Prevention(both individual AND institutional) should not be equated to reductions or denial of treatments. Rather prevention will free up money for the very best treatments that bio-medicine can offer.
But these are both VERY hard sells.
Dr. Rick Lippin
Southampton,Pa
I recently came across your blog and have been reading along. I thought I would leave my first comment. I don’t know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.
Alena
http://grantfoundation.net
“It’s up to politicians to determine how much we should spend on healthcare v. defense v. energy v. foreign aid v. etc… After the healthcare figure is determined (likely 11-12% GDP considering most other industrialized nations spend about that or a little less), the question becomes how best to spread that money around. Bang for the buck if you will. Again, this is an inherently governmental function. Leave it to the elected representatives to determine if it is better for everyone to have primary care or just emergency care.”
When Sarah Palin said “death panel”, this is what she meant. As a child, I was always amazed to read about the doe-eyed docility with which Soviet citizens welcomed rule by apparatchik. Now I understand.
Tim,
What you don’t realize is that medical care is already rationed, just in a quirky and inefficient way.
What do you think happens to patients that have no insurance?
And do you think that Insurance Companies (or Medicare for that matter) pay for everything that a patient may want or need?
So when we spend several hundred thousand dollars to keep a dying cancer patient alive for another couple months, but a pregnant woman without insurance forgoes prenatal care because of the cost why don’t you and Sarah explain how logical and compassionate our system is?
PS FROM ME
The biggest lesson of the entire exhausting most recent US health care reform debate is how terribly dysfunctional our US legislative process has become.
THIS DEBATE REVEALED IN PAINFUL DETAIL HOW VERY SICK OUR CURRENT AMERICAN POLITICAL PROCESS IS.It is a very malignant cancer within us and our nation.
Where are the most promising ideas to begin to remedy this very deep and widespread pathology?
The American people have had it!This could bring our once great nation down.
IF YOU DON’T BELIEVE IT- YOU ARE NAIVE.
Dr. Rick Lippin
Southampton,Pa
note to Tim, while I never realized the soviet citizens were doe-eyed, I sympathize with your discomfort about rationing. does it make it more comfortable to realize that Medicare, among other insurers, has been doing this for years? some people with some conditions can get bariatric surgery. others are denied it. and that’s not unique. my question is why Palin and sympathizers aren’t working to undo all these medicare rules which would, of course, make the program much more expensive.
@ Dr. Rick – you are so right, the way DC works IS the problem, healthcare is a secondary problem caused by the primary problem, the american political system.