Reel back to 1965, the year Medicare and Medicaid legislation was passed. That year Congress gave the “Joint Commission,” a professional accreditation organization established in 1951, the unique authority to inspect hospitals and determine whether they meet the patient health and safety standards required to treat Medicare patients.

And who do you suppose pays the Joint Commission?

The hospitals that are being inspected. “Today, the Joint Commission collects $113 million in annual revenue, mainly from the fees it charges hospitals for telling them whether they comply with federal regulations,” observes Lisa Venn, J.D. M.A., writing on Advocate Alliance. 

Venn, who is the Manager of Compliance at a large teaching hospital, explains that “Deeming authority means that if Joint Commission gives its seal of approval to a hospital, CMS is satisfied that the hospital is following federal regulations. In other words, hospitals enrolling in the accreditation program only have to please one master. And that master is really nice, accrediting 99% of all hospitals it surveys.”

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It’s always worth exploring how health care works in other countries, if for no other reason than that models in other countries give us the chance to see how some of the approaches discussed by American reformers might pan out. What do the experiences of Germany and Netherlands tell us about the possibility of a better mixed public-private system in the United States? How is China’s health care system a cautionary tale of market forces gone wild? The answer to these questions can add to—or detract from—the appeal of certain health care strategies in the U.S.

It’s hard to imagine a country that could provide a more valuable example than Singapore. The Southeast Asian city-state is widely regarded as a health care superstar, especially when compared to the United States. Life expectancy at birth in the U.S. is 78 years; in Singapore, it’s 82 years. The Singaporean infant mortality rate is a mere 2.3 deaths per 1,000 live births, versus 6.4 in the U.S. As some have noted, these trends persist despite the fact that the U.S. has far more caregivers: 2.6 physicians per 1,000 people, compared with 1.4 physicians in Singapore. The United States has 9.4 nurses per 1,000 people; Singapore, just 4.2. Last—but certainly not least—is the issue of spending: the U.S. spends almost 16 percent of its GDP on health care, while Singapore spends a mere 3.7 percent. 

For reformers eager to cite examples proving that their health care ideals are a formula for success, Singapore offers a powerful case study. Its population is healthy, its system isn’t overloaded by medical professionals, and health care spending doesn’t gobble up a huge chunk of its economy. 

So how does Singapore do it?

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Did you know that Japan has found an ingenious way to “create” money that can be used to care for the elderly?  Bernard Lietaer, author of Access to Human Wealth: Money beyond Greed and Scarcity (Access Books, 2003) describes the system in this interview with Ravi Dykema, publisher and editor of Nexus, a leading Holistic journal.

Lietaer begins with the basics, by explaining what money is: “I define money, or currency, as an agreement within a community to use something as a medium of exchange. It’s therefore not a thing, it’s only an agreement – like a marriage, like a business deal…And most of the time, it’s done unconsciously. Nobody’s polled about whether you want to use dollars. We’re living in this money world like fish in water, taking it completely for granted.”

Lietaer, who co-designed and implemented the convergence mechanism to the single European currency system (the Euro), and served as president of the Electronic Payment System in his native Belgium, doesn’t take currencies for granted. He knows that a dollar is simply a piece of paper (which is no longer backed by gold).  It has value because we have agreed that it has value.

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In the July 28th issue of The New Yorker you’ll find an entertaining story by David Samuels that explores the economy of pot in California, where medical marijuana has been legal since 1996. Focusing on the supply and distribution chains that help to get pot in the hands of patients, Samuels weaves a colorful yarn, but one that focuses heavily—and somewhat derisively—on the personalities involved. Given the author’s emphasis on the stereotypical stonerdom surrounding legalization, the casual reader may come away thinking that medical marijuana is just another hippie cause, a 60s-style cultural crusade rather than a question of health care. But that’s not the case. 

Aging Hippies

Samuels’ account of the medical marijuana industry boasts quite a cast. There’s “Captain Blue,” a middle-aged grower with “black and greasy hair” and ill-fitting tee-shirts that “expose his round belly.” He sells weed to dispensaries that supply medicinal marijuana. Then there’s “Lily,” who transports ganja “from Northern California to Blue’s apartment” in the trunk of her car, and a woman named “Cindy 99” who runs a dispensary and who looks like an “adolescent boy’s fantasy of his best friend’s hot older sister.” Finally let’s not forget “Dr. Dean,” the free-wheeling M.D. who regularly prescribes marijuana thanks to a watershed night at his friends’ where he was introduced to marijuana via spiked lollipops and brownies. “It was like Amsterdam,” he dreamily tells Samuels.

If these sound like the characters from a teen stoner movie, that’s certainly the way that they’re represented by Samuels. With such an emphasis on the weed enthusiasts, it’s perhaps unsurprising that the author’s big conclusion about medical marijuana is that it’s just another way to keep the pseudo-subversive indulgences of the 1960s alive. “The legalization of medical marijuana has allowed for the illusion that farming pot can provide opportunities for travel and cool art projects and personal growth,” says Samuels. He then concludes that for aging hippies, “growing ganja lets you feel that you’re still living on the edge,” particularly if you’re a washed-up, wannabe political radical.   

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I am delighted to announce that The Century Foundation has created a working group to look at Medicare Reform.  I’ll be directing it. We’re going to do the work online, communicating with each other on a closed list-serve. In this way, we’ll be able to get a lot done without wasting time traveling to meetings. In the end, we’ll issue a report, and then we’ll get together and host a conference with keynote speakers and panels. (See our Press Release below for more information). 

We’ll be looking at many of the issues I have been discussing on this blog: how physicians are paid; the secretive panel, dominated by specialists, that sets fees; the need to reward providers for quality, not volume; over-paying for Medicare Advantage; overpaying for drugs; unwarranted regional variations in how much Medicare spends in different parts of the country; the need to squeeze the hazardous waste out of the system; the need for a comparative effectiveness institute that is truly insulated from Congress and lobbyists; the need to co-ordinate care; and the need for health IT.

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In my recent post on the issue of quality in health care, I spoke a little about how public opinion can be a poor guide when it comes to understanding the full scope of our health care problems. I noted that, according to Gallup polls, 85 percent of Americans report being satisfied with the quality of care they receive—despite the fact that patients get, on average, just 55 percent of the care that experts recommend for most major medical conditions. The lesson here is clear: if you really want to improve health care in the U.S., you need to look beyond superficial preferences and into the nitty-gritty of how health care is delivered in our system.

This holds true for the issue that Americans care about the most when it comes to health care: making their own care more affordable. But it’s not the public that’s at fault here; when it comes to questions of cost and affordability, people just aren’t being asked the right questions.

Consider the Gallup poll mentioned above, which asked how people felt about the cost and quality of health care. 45 percent of those polled said they were dissatisfied with our health care system’s performance in terms of quality; just 15 percent said the same of their personal experience. In contrast, a whopping 80 percent of respondents said they were dissatisfied with the system’s performance in terms of cost, and 40 percent said the same of their personal experience. Simple enough, right?

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Thanks the unbridled rise in healthcare prices, Medicare is going broke. As I mentioned in a recent post, four years ago the Medicare trust fund that pays for hospital stays started to run out of money.  In 2004 the fund began paying out more than it takes in through payroll taxes.

Since then, the balance in the fund, combined with interest income on that balance, has kept the fund solvent. But in just 11 years, it will be exhausted,” the Medicare Payment Commission reported in its March. “Revenues from payroll taxes collected in that year will cover only 79 percent of projected benefit expenditures.” And each year after 2019, the shortfall will grow larger.

Make no mistake: this is not an example of an inefficient government program spending hand-over-fist without caring whether it is getting a bang for the taxpayer’s buck.  As I discussed in that earlier post, health care prices have been climbing—without a concomitant improvement in patient outcomes or patient satisfaction—in the private sector as well.

Medicare Reform Could Pave the Way for National Reform

Before trying to roll out national health insurance, the next administration needs to address the structural problems that undermine the laissez-faire chaos that we euphemistically refer to as our health care “system.” Otherwise, we run the risk of winding up with a larger version of the dysfunctional, unsustainable system that we have today. Ideally, the administration should make Medicare reform a demonstration project for high quality, affordable universal coverage.

Let me be clear: Medicare reform does not preclude national health reform. To the contrary, by starting with Medicare, and showing what can be done, reformers enhance their chances of winning the larger war.

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The ever-insightful Commonwealth Fund has just released its 2008 National Scorecard on Health System Performance, and reports that “the U.S. health system continues to fall far short of what is attainable, especially given the resources invested. Across 37 core indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with U.S. and international performance benchmarks.” According to Commonwealth’s metrics, overall performance has not improved since 2006.

As we mentioned recently, measuring performance in health care is a tough proposition, so it’s worth discussing Commonwealth’s rating system. The Scorecard looks at five components of what we might call "high-performance health care": healthy lives (preventable mortality & disability), quality (whether care is effective, coordinated, safe, and timely), access, efficiency (waste, appropriateness of care, administrative costs), and equity (disparities of care).

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Over at the” Blog That Ate Manhattan “a NYC physician discusses “Doctors Dropping Medicare: TheDomino Effect” ( http://theblogthatatemanhattan.blogspot.com/)

“When the docs in my area began dropping Medicare, their patients had no where to go but to the docs like me who still participate in the plan.

“And so, over the past year or so, I began seeing more and more new older patients in my practice. The shift in my practice demographic was almost palpable as these new Medicare patients began filling my appointment book months in advance for routine annual visits. Add in a few retiring docs, and the influx of older women became too much to ignore.

“On the day I saw seven new Medicare patients, all coming from the practices that had stopped taking Medicare, I knew that I had to do something.

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It’s safe to say that Americans realize our health care system is in trouble. In polls, people cite paying for health care costs as one of their three most serious economic problems and consistently rank it as a top national priority behind the general economy, gas prices, and Iraq.  Earlier this month a Harris Interactive Survey found that a full one-third of Americans want to rebuild their health care system from scratch, a greater proportion than any European country. Finally, it seems that the American people have disabused themselves of the notion that the U.S. has the best health care in the world.

Or have they? While people may agree that too many Americans are uninsured and that health care costs too much, they still tend to think that the quality of care people receive—regardless how many people actually get it –is top-notch. This is a misconception that goes more or less unaddressed in the mainstream health care debate. That’s a sad omission: if we don’t talk about quality as a separate variable—and understand the reality of our system’s poor performance—we’re going to miss out on a big piece of the health care puzzle.

In May, the New England Journal of Medicine
(NEJM) printed a graphical representation of two Gallup polls from
November 2006 and 2007. The poll results show a deep “split between
public dissatisfaction with the overall system’s performance and
patients’ satisfaction with personal health care. (See below).

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