Over at Centered Politics.com Jim Jaffe once again has written a provocative piece about health care reform. I don’t agree with him on every point. But I am persuaded by his opening premise: the main lesson we need to learn from the 90s involves managed care, not the Clinton effort, which “was a one-off effort with unique problems.”.
The failure of the Clinton plan is all tangled up with the unique personalities and circumstances of the time. Dwelling on the Clintons’ experience only distracts us from the task at hand. The times and the cast of characters involved are very different—as different as Obama and Hillary, Peter Orszag and Ira Magaziner, or Mitch McConnell (Republican leader in the Senate today) and Bob Dole ( the Republican Majority leader in the early 1990s).
Our experiment with “managed care’ is still pertinent because, as Jaffe points out in the excerpt from his post below, the health care reform that the administration proposes aims to lift the quality of care, and contain costs, by weeding out ineffective treatments. This is why the administration has set aside money to fund both comparative effectiveness research and electronic medical records that can provide a database of outcomes.
Of course the phrase “managed care” has been poisoned –in large part because in the 1990s, the media focused only on the downside of managed care (Care Denied!) and rarely on its strengths.
In truth, the original concept had great potential. Dr. Paul Ellwood, who coined the term “health maintenance organization” (HMO) envisioned groups of doctors competing to provide the most effective care at the lowest price. By the 1980s, healthcare reformers understood that high-cost procedures were being done too often; instead of begin helped, patients were harmed.
In theory, HMOs would sort through alternative e treatments, and pay for those that offer the greatest long-term benefits. But instead of competing to show that they offered higher quality care, for-profit HMOs soon began competing to prove that they were less expensive. To be fair, insurers were responding to what the market wanted: after all, most of the people who purchased HMO plans were not patients, they were employers. And as a 1990s poll by the Washington Business Group on Health revealed, “ninety-one percent of the businesses surveyed reported that they looked at cost when choosing health plans, while 84 percent considered service to employees and only 37 percent considered quality benchmarks. In the 1980s, the cost of healthcare had spiraled; employers were desperate to rein in healthcare inflation.
Moreover, HMOs were wary of competing on quality. What what happen if an insurer advertised that his plan’s network of doctors had refined a system for managing diabetes? Every diabetic in the region would flock to the plan. No insurance company wants to attract too many sick customers.
Meanwhile, insurers knew that they would gain market-share if they kept premiums low. So HMOs began saying “no” to the most expensive treatments. Too often this meant that they refused to cover a procedure simply because it was costly.
But in other cases the HMOs were right: they were refusing to pay for a drug because there was no medical evidence that it worked. As a society, we cannot afford to pay for every untested product or procedure that a desperate patient might want to try. In most cases, subjecting patients to experimental treatments makes sense only if they are part of a controlled clinical trial. Then, our dollars are well-spent; even if the procedure fails, we learn something that can help future patients.
But in the mid 1990s, the idea “evidence-based medicine” was still relatively unknown. So even if for-profit insurers had done a thorough and conscientious job of examining the data and looking at outcomes (which most didn’t) the majority patients and doctors simply would not have accepted the notion that they shouldn’t try the newest, cutting edge product or procedure, even if there was no date showing that it offered greater benefits than older treatments—and even if we had little information about risks.
Most Americans still assumed that if a drug is newer, and more expensive, it must be safer and more effective. Today a growing number of physicians and patients realize that this just isn’t true.
Looking back on the managed care experiment, two facts stand out. As Jaffe observes below, “managed care” did rein in health care spending: in the mid-1990s, health care premiums flattened out. And there is no persuasive data suggesting that the overall health of the population suffered.
Nevertheless, the backlash against managed care was fierce. How Jaffe asks, do we rephrase the idea, and explain it to the public today?
Reform Lessons
By Jim Jaffe, Health Care Editor
As reprinted from http://centeredpolitics.com/090308%20Jaffe%20Reform%20Lessons.htm at CenteredPolitics.com
The stage has now been set to argue, once again, the issues
that were raised so ineptly during the managed care episode. The idea
of managed care – finding the best way to deal with a problem and
making that the default approach – is a pillar of reforms now under
consideration. That’s why the same arguments
that quickly forced managed care into retreat are being used again
today and why it is important to come up with a compelling response –
something a bit more compelling than “this is not your father’s managed
care.”
There
were some massive failures of communication, starting with the basic
idea, which involved the use of evidence-based medicine to maximize the
odds that doctors would use the right therapy at the right price. It
is important to acknowledge that the goal was to deliver good care for
most patients most of the time rather than delivering the best possible
care to every patient every time, an improbable goal not worthy of
serious consideration outside of Lake Woebegone.
When
the issue arose in the 90s, scathing media reports fed by unhappy
providers convinced employers to back away from that approach and move
instead to plans where workers were forced to pay more for a broader
array of choices – despite data showing that about half of consumers
prefer the idea of paying less for a plan that offers fewer choices.
But
the idea is a compelling one that we keep coming back to. What
happened a decade ago was an echo of Richard Nixon’s efforts a quarter
century before to encourage the growth of health maintenance
organizations. In each case, the idea is promoting evidence-based
medicine.
Think of
it as a system not unlike synchronizing traffic lights to maximize
traffic flow. Done right, it allows all to move a bit faster. But I
could go faster if all other traffic stopped to let me by. Or think of
an emergency room that does triage well, treating the sickest first.
My care would be better if they simply bumped me to the head of the
queue when I arrived irrespective of my complaint.
If
things work right with managed care, you maximize the odds of getting
care that is at least adequate, while simultaneously lowering the odds
that you’ll get care that is either extraordinarily good or bad. In
medicine, that means simply waiting a bit when dealing with problems
that often solved themselves, using simple tests (like x-rays) that
could adequately provide needed information rather than complex,
expensive ones (like MRIs or CAT scans), trying drugs before resorting
to surgery when both were possibilities and using a generic drug with a
track record before switching to an expensive new option where side
effects remained a mystery.
All
this was based on a theory – called science by some — that those with
large amounts of data knew what worked best and should share their
findings with those delivering the care, which is a hard theory to
argue with. Unfortunately, those who knew the most tended to be
affiliated with insurance companies, who are at an inherent
disadvantage when dealing with the doctors we have a personal
relationship with and rely on.
These
managed care firms were perceived, not entirely incorrectly, as being
solely interested in saving a buck by saying no – which is a profitable
habit familiar to those who deal with any type of insurance. Doctors
were understandably impatient with insurers who not only imposed costly
new administrative requirements before approving care, but sometimes
responded by terming the care they recommended as inappropriate, a
decision that caused the doctors psychological and financial discomfort.
Patients
forced to choose between face-to-face English-language conversations
with their respected doctor and bureaucratic insurance firm responses
delivered from disembodied voices at call centers had a tendency to
favor the former and their resulting frustration ultimately resulted in
a retreat from managed care, which is recalled today only via some sour
jokes about HMOs. What is less realized or remembered is that managed
care worked. Despite rhetoric about their power, insurance companies
proved to be ineffective communicators at best, never convincing people
that their goal (at least their stated goal at least part of the time)
was to get the best possible care from the best providers.
Despite
complaints, there’s no evidence that patients stayed sick longer or
died more often during this period and there is evidence that medical costs
moderated. When managed care disappeared, they again grew explosively.
Often employers insulated themselves by having workers pay the extra
costs involved. Basically, they said workers who wanted extra choices
would have to pay extra for it.
Another
painful residue of this experiment were a series of “any willing
provider” laws enacted by a number of states that required insurers to
include any credentialed doctor who was willing to live by their rules,
thereby sabotaging insurer efforts to push patients toward the most
efficient providers.
Whether promoters of change have learned enough to make a better case this time is a key question.
As usual the concepts of care vs insurance are getting conflated.
Insurance is simply a way to spread risk. If done right the excess of revenues over payout is strictly a function of intention. That is a non-profit (or government administered) program should have no excess, while a private firm should. Obviously if these two types of organizations are in direct competition the for-profit will be at a disadvantage. Claims that they can be more efficient have turned either to be not true or only because they substituted low-wage workers for generally unionized government employees.
Countries, like Germany, which have non-profit insurance companies are not readily comparable to what we are used to in the US. The Blues used to be non-profit, but many no longer are, and those that remain have forgotten their mission and tend to go in for internal spending that emulates for-profit firms. This means fancy buildings, high salaries and other trappings.
The crucial issue is who gets to determine how health care is provided. The experience with HMO’s showed their conflict of interest and proved unpopular. For-profit insurance firms don’t directly control treatment, but do so indirectly by their coverage policies. This is also a conflict of interest.
Only a system where care is not associated with who provides the insurance can work well. Then insurance companies provide only a clerical or administrative function and it is relatively unimportant whether this is done by private firms, the government directly or by contracting the work out.
Paying and decision making need to be kept separate if discussions are going to make any sense. Obama is fudging this somewhat, not a good sign.
Robert:
Could you share how the not-for-profit insurers in Germany operate differently from those here?
Do you think there is potential with the 501(c)(9) as a tax exempt insurer?
Don Levit
One problem with the “managed care model” managed by insurers as opposed to medical “experts” is that it doesn’t support how medical care is provided. This is one aspect of Robert D. Feinman’s comment (separating the financing from the delivery).
Health care services are not a “product” in the sense of a “commodity,” and therefore it’s difficult to determine what is being “managed.” It’s obvious that “health care services are not uniform in quality or character” (definition of a “commodity”)
even for treatment of the same condition. A single patient can present with complaints and receive different diagnoses from different diagnosticians, and
the diagnosis will determine what treatment is given. Several (experimental) studies show that different radiologists
read the same x-rays and some diagnose that a disease is
present and some diagnose that a disease is absent. A university hospital may be stellar in providing a particular surgery or high-risk procedure while a community hospital may provide that same surgery very poorly and should not even be providing high-risk procedures. Even with the same diagnosis,
different specialists prescribe different treatments depending on their specialty
and focus. Different regions of the US provide different amounts of various
procedures even though the health status of their populations is similar.
Depending on the results of these situations, differences will occur in what kind of health services are provided (or not), how much is provided, why it is provided (or not), and where it is provided. Of course, the results of these decisions impact whether and how much insurers will pay out.
As a “member” of one of the earliest HMO’s in the ’80’s, I have to say that Jaffe’s description is not how HMO’s were sold to employers and employees. Patients’ care was described as being “managed” by a primary care provider who would have all the information about a patient’s medical history and knowledge about everything the patient needed. In addition, these providers would be the “gatekeeper” to any necessary care by specialists. This would keep costs down and provide a regular primary care provider for each patient (this whole model is being revived in the “medical home” idea; note the non-use of the dreaded “managed care” name). This model made eminent sense to me and I eagerly joined up.
The problem was that the insurers became the “gatekeepers” for financial reasons, rather than the medical providers acting as the “gatekeepers” for patient health reasons (they are, after all, the agents who make medical utilization decisions on behalf of patients). The HMO’s restricted access to specialists and consistently second-guessed medical decisions, without medical justifications. The model may have had the effect of improving the quality of care overall with continued experience and transparency of outcomes data (which they considered proprietary and never shared). But their purported, publicly-advertised raison d’etre was 1)to lower costs by using primary and preventive care a lot; and 2)integrated medical care for patients.
I put the quote in the wrong place (even though I previewed it–a clear case of “confirmation bias”). It should have read: ‘It’s obvious that health care services are not “uniform in quality or character” (definition of a “commodity”)
even for treatment of the same condition.’
I put the quote in the wrong place, even though I previewed it (a clear case of “confirmation bias”). It should have read: ‘It’s obvious that health care services are not “uniform in quality or character” (definition of a “commodity”)
even for treatment of the same condition.’
To ACarroll
You raise a good point. When the push toward HMOs began in the Nixon era, all we knew was the closed panel model like Kaiser where the gatekeeper concept was a real possibility. Problem was that we never had either the supply of or demand for HMOs that was anticipated. managed care entities like PPOs were seen as “HMO lite” that gave patients greater choices (leading to the coordination problem you mention) and wasn’t constrained by how fast Kaiser or HIP chose to expand. apparently only a limited number of patients find the HMO model attractive.
“Unfortunately, those who knew the most tended to be affiliated with insurance companies, who are at an inherent disadvantage when dealing with the doctors we have a personal relationship with and rely on.”
The insurance companies impeded the improvement of healthcare quality by maintaining their outcomes data as a proprietary asset, even on an aggregated basis; they had no interest in improving the “system”, but only in minimizing costs (i.e., bottom line focus).
Another point: In the ’80’s, I designed a LATCH (Literature Attached to Charts) program for a community hospital with a nursing school. The idea was for the medical librarian to go on patient rounds with the clinicians and provide research articles on the patients’ admitting diagnoses, which were then attached to the patients’ charts (pre-internet days). This idea was new and had not penetrated very much, although there were a couple of programs in academic medical centers. I found out why when the lawyers refused to allow the program to be deployed. Their argument was, “If the patient knows that the doctor knew the research and the doctor doesn’t follow it and something goes wrong, we’ll be sued. On the other hand, if the patient knows that the doctor knew the research and the doctor does follow it and something goes wrong, we’ll be sued.”
Heavy-handed “risk management” is also a reason that clinicians don’t “know the most.”
Jim:
The HMO that I described was a true MCO owned and managed by the insurance company, with strict rules about access. PPO’s followed on, at least in my experience, after the backlash to the HMO’s and the public outcry for the state insurance regulators to look into their practices.
I also suspect (though not based on research) that the specialist professions exerted their political clout, since they were the object of much of the cost-cutting.
I agree that insurance companies “became the managers in the managed care experiment”
That rendered both doctors and patients miserable.
Can we learn from the HMO experiment? We had better. We are much worse off in 2009 than we were in 1994-1995
Dr. Rick Lippin
Southampton,Pa
It’s great to see this line of argument being presented, Maggie and Jim. The failure to make the case for what was good about managed care (both the concept and to some extent the execution) is the single largest factor, I think, preventing us from major reforms to the system today.
By “failure to make the case” what I really mean is: the almost complete victory of the provider lobbies in the messaging wars. There is no sizable constituency pushing for the replacement of fee for service with another payment model. There is no sizable constituency pushing strongly for evidence-based medicine. It simply isn’t on the public’s radar.
And given that the public does not understand the cost drivers, it does not direct its outrage wisely. We have the most expensive system in the world by far, and yet far more outrage is directed at cost control measures by insurers than on over-utilization or unnecessarily ineffective/inefficient treatments.
The trust the public puts in providers–nurses, physicins, hospitals–means that any reform which threatens to reduce their revenue is essentially a dead letter because all provider groups have to say is some version of “this law will get in the way of my delivering care to needy people” and support for the reform will collapse.
And in case anyone was wondering, the shot across the bow from the AMA has already occurred:
http://www.healthleadersmedia.com/content/229394/topic/WS_HLM2_HR/AMA-to-White-House-Dont-Dictate-Care.html
President Obama is calling for flexibility and compromise from stakeholders in the healthcare reform debate, but the nation’s largest physicians’ organization warns that any attempts by the federal government to use evidence-based medicine to dictate how physicians provide individualized care would be a deal breaker.
In an interview with HealthLeaders Media, American Medical Association President Nancy Nielsen, MD, says she’s already made that clear in her two summit meetings with the president in the last two weeks.
“Government control of the doctor-patient relationship is a no deal,” Nielsen says. “Although there is no question that we need to be sure that the best science and evidence is used when we deal with a patient, it isn’t that easy. People who think that ‘we just put out a guideline and if you don’t follow it, we will smack you down,’ well, it isn’t that simple because patients aren’t that simple. What we have to get to is the concept that what needs to be done is what is appropriate for that patient.”
To follow up on what I just wrote: Real reform will first require education of the public, and a long diet of examples of how the perverse incentives in the system have led to practices that waste our dollars but don’t improve the quality of care. People need to be outraged about the waste and see it directly impacting the high cost of care (their premiums, their taxes, their out of pocket cost)
But that is a multi-year project. That is one reason why I say that we should go ahead with universal health care now with only minor system reforms. Because we simply can’t get major reforms now, despite Orzag’s talk, with or without universal health care.
Another reason to go for universal care first is precisely so that the public can turn its attention from coverage/access issues and focus it on the issue of value (quality as a function of cost). Not only will universal coverage free the public, but the higher expense (whether in the form of new taxes or bigger deficits) will help to generate the outrage we need over the waste in the system. We may even find that Republicans become more zealous than Democrats about reforms that improve efficiency once more tax dollars are involved.
But there is no shortcut to laying the groundwork for major reforms in the media with stories and essays about wasted care.
I do think we can take a few steps in the direction of reform now, such as in the area of HIT with the $20 billion HITECH act. EMR data mining and electronic clinical data exchange will revolutionize care within a decade. But they’ll need a lot of help with payment reform, among other things, to get our costs down to Swiss levels.
As I’ve debated with Maggie before, I think our long term goal has to be to reduce the share of GDP devoted to health care. I think the next most expensive nation on Earth for healthcare is Switzerland at around 13% of GDP. That should be the goal. It is a natural target not only because at that point we will be in line with the rest of the world (at the high end) but it also roughly corresponds to the figure of 30% unnecessary cost in our system that gets thrown around based on the Dartmouth data.
I think there are several issues at work here. From the perspective of the Mayo Clinic Health Policy Center, covering everyone is one, but only one, goal. If we don’t begin demanding value in the system — better outcomes, better service, fewer errors, at a lower cost — covering everyone doesn’t achieve the goal of better health care for the country.
If the payment system were adjusted to reward providers who deliver good value, and patients who choose those providers, we would be looking at a different kind of health care system.
And value is determined, in part, by evidence-based medicine. Perhaps we can begin talking about value rather than “managed care” — it’s hard to disagree that we need better value.
Jane, j.d.,
(Will be back to respond to everyone else)
Jane–I agree completely.
On the one hand, I think Jim is quite right (and courageous) in what he says about what we need to learn from the “managed care” of the 1990s.
But, gong forward we cannot use the phrase “managed care.”
As you suggest it’s far less provocative to simply suggest that we need “value” for our healthcare dollars: few could argue with that.
And, as you say, “universal coverage” does not define health care reform: “covering everyone doesn’t achieve the goal of better health care for the country.”
We have to change the way we pay for healthcare “to reward providers who deliver good value, and patients who choose those providers.”
j.d. —
I agree that “real reform will require education . ..and will be a multi-year project.”
But when you suggest that we should “go ahead with universal coverage now” with only minor structural reforms to the healthc are system, I have to ask “where will we find the money”?
You write “the higher expense (whether in the form of new taxes or bigger deficits) will help to generate the outrage we need over the waste in the system”
No,we’re not talking about generating outrage. We’re talking about generating an eocnomic collapse that we cannot afford.
If we try to fund universal coverage with bigger deficits, we insure an eocnomic catastrophe that will mean a much lower standard of living in the U.S, for years to come. (Other countries will stop buying our Treasuries; see budget director Peter Orszag on what this will mean.)
I’m not talking about the wealthy having to give up their McMansions. I’m talking about the coutnry as a whole not being able to keep up with other countries in terms of education and healthcare, while our middle-class and upper-middle-class are forced to ratchet down their standard of living in meaningful ways: not enough money to send their kids to college; forced sales of their homes while the real estate market is still scraping bottom . .
As for financing a 13% increase in the nation’s healthcare bill while covering everyone through tax increases (see my most recent post on Gawande, part 1, for the explanation of why covering the uninsured and underinsured means a 13% increase in the nation’s health care bill) ) this is just not possible in the midst of a severe recession.
Already, even Democrats such as Bauscus, the chair of the Senate Finance Committee, ) are balking at the idea of raising taxes on the wealthiest 1.8%. in order to raise just part of the money needed for universal coverage.
To do what you propose, we would need a major tax hikes for families earning over, say, $150,000.
In this economy, that is not happening.
We cannot expand healthcare coverage without simultaneously cutting spending.
The needed reforms will be diffcult (see part
1 and part 2 of the new Gawande post) and they will take both time and money.
As Gawande has suggested,
heatlhhcare reform will have to be done in “stages.” In is latest testimony he talks about 2013 as a target. (No coincidence, this is also Obama’s and White House budget director Peter Orszag’s stated “goal”
I would be delighted if we are able to pass a bill this year that makes the needed reforms while also guarnteeing universal coverage now.
But when I look at the numbers and listen to the conservatives in Congress, I just don’t see how that will happen.
And trying to roll out universal coverage without the needed funds–even if Obama could get the votes. . .would gurantee an implosion– a
collapse of our healthcare “system” that would set reform back another 10 or 20 years.
We simply wouldn’t be able to deliver on what we had promised, and universal covverage would collapse.
Will be back to respond to everyone else! Hope you keep talking to each other
JD thanks for your first post:
You write “The failure to make the case for what was good about managed care (both the concept and to some extent the execution) is the single largest factor, I think, preventing us from major reforms to the system today”
Yes. This, I think, is Jim’s central insight.
You also point out that: “far more outrage is directed at cost control measures by insurers than on over-utilization or unnecessarily ineffective/inefficient treatments.”
This is entirely true, and as you say, the AMA is trying to fan this outrage
But the AMA is not the force that it once was.
The AMA no longer represents the majority of doctors in America.
A great many yunger dotors and women docors do not feel that the AMA repesents their goals or values. .
At this point,most of the AMA’s members are older, male physicians.
Today, even if doctors belong to the AMA,the majority identify, much more storngly, with their specialty group: family docs, hospitalists, internists, surgeons, etc.
As for patients, I think that they, too, are beginning to be aware of the serious flaws in our system.
Today, the Business Roundtable (a pretty conservative business group) issued a report explainign that U.S. healthcare is very far from being the best in the world.
Maggie,
I am not sure where you get the idea that we can’t deficit spend to pay for a few years of universal health care before Americans get the fear of God in them and support the big reforms that you and I both want.
Spending an extra $100 billion (give or take) for a few years will not bring down the system in a “collapse.” I don’t think that is plausible. We’re talking about a $2.5 trillion dollar sector of the economy and a $3.5 trillion dollar Federal budget. $100 billion, or $150 billion, of additional annual Federal spending for 2-5 years will not bring on a collapse.
It will be money that we have to pay back later, on top of a lot more money, and I’m not any happier about that than you are. I can do the math on the per capita share of debt, and understand how servicing the debt is a drag on the economy.
What you don’t acknowledge, perhaps because you don’t agree, is my tactical point: getting UHC now will set forces in motion to overcome the barriers to reform–barriers that we cannot now overcome. But this is a point about human psychology and American politics. It is not a point about economics or ideal (first-best) policy. If you disagree on the psychology and politics, I haven’t really heard that case made.
You wrote: “No,we’re not talking about generating outrage. We’re talking about generating an eocnomic collapse that we cannot afford.”
These are not mutually exclusive options, which is another reason why I don’t think you’ve really acknowledged the point I’m arguing, let alone responded to it. I’m talking about a way to get more reform faster than if we try the approach of insisting that expansions in coverage can only come hand-in-hand with either (a) tax increases or (b) reforms to cancel out the incremental cost of the added coverage. My whole point is doing UHC first is likely to get us the savings and the reform we want faster. My point is that the UHC-first approach is actually more fiscally responsible, not because UHC is automatically cheaper, but because it sets in motion a whole new set of perceptions and constituencies that are needed to overcome the enormous barriers to reforming the payment system. To disagree with me you have to disagree with that.
I’ll respond on the 10-13% increase in the next thread.
Maggie,
Regarding the AMA and the prospects for healthcare and health insurance reform, the key issue, I think, is its influence with members of Congress and its ability to spread PAC money around. It doesn’t matter that most doctors are not AMA members or that younger doctors don’t think the AMA represents their views. The AMA continues to exert a strong influence over legislation that affects its interests. It has a history, spanning decades, of opposing any changes that would reduce its members’ power, independence or income, and it is likely to remain, along with the hospital lobby, the greatest obstacle to substantive reform.
Medicare is already a single payer system that provides universal coverage to the 65 and over population along with several million others who meet its disability criteria. CMS needs to provide the leadership to drive payment reform in order to reduce medical cost growth over the long term. Private insurers are not considered to have the “moral authority” to do it on their own unless and until CMS does it first. Whether we have universal coverage for the rest of the population or not, doctors and hospitals will fight CMS’ payment reform efforts if they think it will adversely affect their interests. We need to have the fight sooner rather than later.
jd:
I can see why you would support additional deficit spending with little repurcussions.
We have had continuous deficits for most of the past 40 years, and nothing catastrophic has happened.
The total debt is around $10trillion, with half of that debt representing intragovernmental debt.
Intragovernmental debt is mostly represented by the Social Security and Medicare Trust Funds borrowing from the Treasury.
The government considers this debt is also represented by a corresponding asset, the full faith and credit of the U.S. Government (an intangible asset).
What other organization backs half of its debt, with an intangible asset?
What other entity could issue debt, and consider it a “wash,” from an accounting perspective, becaues a corresponding intangible asset is created with the debt.
This is creating something out of nothing. The only intangible asset that can do this is God Himself!
Don Levit
j.d. Don, Barry, ACarroll (two comments)
Thanks for your comments.
Don–I’m afraid you are right.
j.d. — what Don is saying is that For a long time, we’ve stayed afloat on deficit spending, but jig is up.
Our deficit spending meant that the rest of the world sold us their goods in exchange for our paper (Treasuries– they bought our Treasury bonds (i.e. our debt) and thus we were able to buy their goods.)
But now our Treasuries are worth less (paying very low interest rates)
If our deficit spending grows, the world will lose its trust in U.S. Treasuries as a safe haven for its savings.
You say “I don’t understand why we can’t continue deficit spending for a few years.”
J.D., This eocnoomic melt-down is serious: we are on the edge of cliff.
Unemployment is heading toward 10%–and beyond.
Right now, we’re enjoying a “sucker rally” in the stock market.
My sources predict that,when it’s over, the S&P will head down to 500.
California may well default on its debt.
Times have changed. We can no longer afford to be cavalier and think that we can afford “a few more years of deficit spending.”
WE now live in a global econoomy, People outside the U.S. now own well over half of our debt (our treasuries) and the rest of the world is not going to cut us that much slack.
And from our own point of view, pouring money into ineffective healthcare (wasting $1 out of $3) is not in the interset of American patients. Too many are hurt by ineffective, unproven and unsafe care.
Barry–
You are absolutely right: the AMA has the money to give it great power as a lobby.
In that sense, it really doesn’t matter how many doctors belong to the AMA.
But I still see doctors as, at least postentially, a great political force.
Patients tend to trust their own doctors. If doctors begin talking to their patients about health care reform–and Obama’s plan– I think they can be hugely helpful in reassuing patients that they would be able to keep their employer-based insurance–and their doctor.
But at the same time– if something happened to their insurance–or a friend’s or relative’s insurance–they would have a good fall-back.
More than half of all doctors are now in favor of major structural reforms in our healthcare system. The majority are not in favor of switching to a single-payer plan, but they are comfortable with something like the Obama plan.
I hope they will speak out; they really could influence public opinion.
ACarroll-
You write: ” a LATCH (Literature Attached to Charts) program for a community hospital with a nursing school. The idea was for the medical librarian to go on patient rounds with the clinicians and provide research articles on the patients’ admitting diagnoses, which were then attached to the patients’ charts (pre-internet days). This idea was new and had not penetrated very much, although there were a couple of programs in academic medical centers. I found out why when the lawyers refused to allow the program to be deployed. Their argument was, “If the patient knows that the doctor knew the research and the doctor doesn’t follow it and something goes wrong, we’ll be sued. On the other hand, if the patient knows that the doctor knew the research and the doctor does follow it and something goes wrong, we’ll be sued.”
This is very interesting.
Today, clearly we want to see that medical reserach organized, on line, in a way that doctors can easily access by diagnosis.
(This is what hte proposed
Federal Health Bosard is supposed to do.)
And there are already proposals to portect doctors who follow the guildeines for best practice against lawsuits.
ACarroll, you also offer ane excellent description (in an earlier comment) f what went wrong with HMOs:
“As a ‘member’ of one of the earliest HMO’s in the ’80’s, I have to say that Jaffe’s description is not how HMO’s were sold to employers and employees. Patients’ care was described as being “managed” by a primary care provider who would have all the information about a patient’s medical history and knowledge about everything the patient needed. In addition, these providers would be the “gatekeeper” to any necessary care by specialists. This would keep costs down and provide a regular primary care provider for each patient (this whole model is being revived in the “medical home” idea; note the non-use of the dreaded “managed care” name). This model made eminent sense to me and I eagerly joined up.
The problem was that the insurers became the “gatekeepers” for financial reasons, rather than the medical providers acting as the “gatekeepers” for patient health reasons (they are, after all, the agents who make medical utilization decisions on behalf of patients). The HMO’s restricted access to specialists and consistently second-guessed medical decisions, without medical justifications”
That’s exactly what happened. I, too, watched it happening.
I believe what we can learn from the 90s about health reform is that less than a holistic approach (primary care and prevention) to managing health will further make care and coverage less affordable. We need to get the incentives aligned for both patient AND provider. Both need skin in the game for the patient to get better. Pun intended!
Advocates: Preventive care key to cutting costs
By Joshua Riley • GANNETT NEW JERSEY • February 18, 2009 • Asbury Park Press
http://www.app.com/article/20090218/NEWS01/902180374/1004/NEWS01
NEPTUNE — A new health care model that provides doctor reimbursements and other incentives for preventive and aggressive chronic-disease treatment must be adopted as the cost of treating mismanaged, preventable diseases is becoming overwhelming and often unnecessary, some experts say.
Representatives of the Partnership to Fight Chronic Disease, who met with the Asbury Park Press editorial board Tuesday, made this case, saying $7.5 billion is spent annually on the treatment of preventable diseases in the state. The partnership is composed of more than 100 patient, provider and community organizations, business and labor groups and health policy experts.
With health care reform on the Obama administration’s agenda, the organization is fighting for universal health care access, which would include prevention and treatment of chronic disease.
Last year, state Sen. Joseph F. Vitale, D-Middlesex, sponsored the legislation that now provides universal health care to residents under the age of 18, and he hopes New Jersey will provide universal care for all uninsured residents by 2011.
David L. Knowlton, president and CEO of New Jersey Health Care Quality Institute, and Donald Sico, president and CEO of Donald Sico & Co., a public relations company, told the editorial board that the partnership is promoting prevention programs and appealing to politicians to include in any reform bill programs to combat chronic disease.
“Where the money is, is in preventing these things (diseases) or treating these things aggressively, early, so we are not paying for them down the road,” Knowlton said. “(The partnership) said, “Let’s put this out front and center and show people how much money is on the table.’ ”
If insurers changed their policies, the costs of treating preventable ailments such as pulmonary and heart disease and diabetes, which account for 50 percent of the state’s spending on chronic health diseases, would fall dramatically, he said.
There are many models throughout the state that are getting good results and should be replicated elsewhere, Knowlton said. In one program in Camden, Dr. Jeffrey Brenner — who Knowlton said was the only family practitioner in the city — used data from a hospital emergency room to find frequent users of its emergency services and took more than 30 of them into his private practice.
One of Brenner’s patients, who was homeless, obese, asthmatic and diabetic, had been in the emergency room more than 150 times in a three-year period. Brenner made sure the man had a proper inhaler, and could get and use his medications regularly, Knowlton said. Brenner also worked with social services to get him into a homeless shelter, which now has support groups for people with chronic diseases, Knowlton said.
This one patient saved the system millions of dollars in health care costs by ending his use of emergency services, he said.
A person with even one of these diseases will enter the emergency room frequently if they are not getting proper treatment between visits, Knowlton said. They will keep ending up in the ER “unless you work prospectively with these people, and try to attack the chronic disease early,” Knowlton said.
Knowlton said that Brenner’s practice could be used as a model.
As of now, Knowlton said, insurance companies do not reimburse doctors for this sort of social work or other preventive care, which, in the long run, would save the insurers and taxpayers huge sums of money.