Wednesday, September 16, 2009

A Forum for Discussion on Health Care Reform

Another opinion generated from the discussion was e mailed by a Connecticut architect. I want to encourage all of you to send in your comments and rebuttals to any of the ideas expressed in this forum. Maybe we can actually get a consensus of good ideas that address some of the concerns raised:

Hi Ralph,

Thank you for this very interesting article on US healthcare. Our healthcare system is definitely a nightmare. It really doesn’t matter who is running the insurance programs in this country. We need to get real, stop the greed and stop making victims out of people. Our country needs a total health and mental cleansing – eat healthy, exercise, stop the unnecessary sweet drinks, junk and fast foods, turn off the TVs and computers - the drug ads have been making hypochondriacs out of Americans for years and most TV shows are garbage. Our society has become so lazy, they want it all now, a lot of it and cheap. It fits with the housing market and the American automobiles situation. That’s my 5 cent.


Monday, September 14, 2009

A Forum for Discussion on Health Care Reform: Cont'd

An Economist's Point of View

In continuing the discussion on heath care reform we have some thoughts from a former economist with the World Bank:

As an outsider, there are several ways to look at the issue: 1. Discussing technicalities, namely the tools to implement the president's option, including its costs and benefits; 2. To focus on the fundamental policy synthesized by the slogan "No one left behind", which contains two elements (a) affirmation of a social justice pursuit, and (b) depicting the society as a moving system with the implicit assumption that it is forging ahead (But, logically, there is also the possibility that the movement is backwards); 3 the political battle that pits the president against competing commercial interests (e.g. insurance companies and their adjuncts) and a medical profession with diverse views but essentially leaning toward opposition (Right?).

At all levels, it seems that the fight involves heavy lobby work, congressional influences, media intervention and (from my generic point of observation) is conducted mostly with the use of code words (such as socialism) or just buzz words that push the issues under discussion into the quagmire of stereotypes about class (poor), ideology (looser in the "survival of the fittest") and political issue (immigrants).

Of the three aspects, the third is the most interesting for the external observers. Will a very popular president, seen as an exceptional person worldwide, be beaten by parochial sectoral interests? Will a policy be rejected even after having been streamlined to a simple "option", an option further cast in basic terms?

The jury is still out, out perhaps in the streets of Washington. I am convinced that a lot of insight may be drawn from the outcome, well beyond the immediate issue of health insurance. It will be interesting to see.


Saturday, September 12, 2009

A Forum for Discussion on Health Care Reform

Recently I posted to many of my friends and family a link to an article written in The Atlantic. It had, what I thought, some thought provoking ideas about health care reform and the state of medicine in this country. With all the partisan information being disseminated and flung about like so much flotsam on a raging sea, I was hoping to get some considered response to this and generate some further discussion from you out there in the ether. For those of you who never read the article it can be found at this link:

Since then I have received some responses that I believe are worth posting.They bring into the discussion some personal experiences that need to be aired so we may be able to best determine what works, what doesn't work, what the health care professionals in the trenches think, what those in the business legitimately fear most about potential reform (and how we can best address those concerns), what we can practically afford to provide to the population as a whole , etc etc.

I hope to gather my thoughts on this and write my own prescription for reform but for now I am delighted to offer several responses from a few of you with something to say. I hope you choose to offer your own comments and continue to elevate this important discussion: For now here are two interesting perspectives.

Reply #1 A Physician's response:

Let me preface my comment with some background information. I am a physician, specifically a Radiologist. I am salaried by a University. I work at a critical access, not for profit hospital. I do not order exams. The referring doctor does that. So there is no "moral" issues. I cannot refer cases to myself. (See the STARK LAWS).

First: I couldn't disagree more with the premise that health care should be run like business. That is part of the problem that exist now in medicine. In the good old days that the basic unit of work ( and reimbursement) was between the physician and the patient. Recently there are any number of business trained administrators trying to get as much profit out of the process as possible. They have nothing to do with the care delivered but they have everything to say about the money. In the "good old days" any profit was channeled back into hospital refurbishment, technical improvements, personnel and indigent care. The new working model for so many hospitals is demoralizing for the health care workers who work in them. The nurses and technologists and other personnel are chronically understaffed and underpaid. There is little to no "improvement" unless it can be shown that it will make money. "Quality of care" is a language not spoken by administrators. If you want to make changes that are in the best interest of quality, you may as well tell your dog because he /she will listen more closely. So much for why the hospital "killed your dad".
Second: Government programs: Medicaid and Medicare reimburse at a rate which often does not cover the cost of the procedure. For years the American College of Radiology encouraged all Radiologists to continue to provide mammograms even though we lost money on every exam. That is just one example. Also, as many in the auto industry are now learning with the current "cash for clunkers" deal, the government will deny your billing because you forgot to cross a "t" or dot an "i". And literally will not consider paying any claim that is more than 3 months old. Now after your office staff submits your bill and gets denied over and over and argue and resubmit, the cost (which didn't cover the expense to begin with) now becomes even less. Now we need increased office staff to claim the payment we are due. Add 8% to the bill just for billing!
Third: Insurance Companies:Because the government reimbursements are so low, all insurers expect the same costs to their clients. But if the government is below cost in some cases, the difference has to be made up somewhere. And no one wants to be the person who is paying more. So all this money we all pay for insurance, where is it going? Look at their annual profits!
Fourth: Drug companies marketing directly to patients? Seriously what is the possible motive for that? Here the Walmarts of the world are making a huge difference to patients. Kudos.
Fifth: Litigation: After reimbursements went down the watch words became "economy of scale" and we worked faster and longer hours for the same reimbursement. When in training we were held to a work level of 10-12,00 case per year. Now the average Radiologist is reading 22,000 -25,000 cases per year to try and maintain salary. Enter litigation. You cannot go faster and provide quality. And mistakes are inevitable. Many Radiologists decided to stop providing mammograms because the cost of their malpractice insurance (in some cases, even without any prior claims, there were no insurers that would provide coverage). In some fields the cost of malpractice insurance costs more than the doctors make. So why should they stay in business? Would you? The current health care reforms do not address litigation. Laws are made by lawyers the ultimate self interest group.

Sixth: Patients are not who you think they are. People view themselves as the victims in this scenario. But there are large numbers of patients who come to the ER seeking drugs. They complain of pain. They are well versed in what complaint will get them which test and what medication... Some prick their fingers and put drops of blood in their urine to get pain meds... hematuria requires the ER doctor to order a CT scan to look for kidney stone ... if they don't and miss a stone, they get sued). The young women learn early that they will be covered by WIC for two years if they are pregnant. So in order to get this payment they need a diagnosis. At age 16 they come to the ER complaining of pelvic pain. The ER doc has to order a pelvic ultrasound. And when we document the pregnancy she is on easy street for 2 years (if you call kids easy street). But I have seen women with 9 and 10 consecutive pregnancies, all children later taken away for neglect and become wards of the state where they are an additional burden on society.
The young men who do not want to work come in complaining of back pain. So they get examined and x-rayed (again heaven forbid you miss a compression fracture you will get sued). And many get put on Oxycontin. They turn around, go out into the parking lot and sell their prescription for $3,000.
Fifth: Socialization of medicine: I had the opportunity to see Howard Dean's insurance reforms and their effects first hand when I lived and worked in Vermont. He created Doctor Dinosaur which made health care for children in families making less than $60,000 a year free (government reimbursed below cost). The intention might be laudable but the result was that it put out of business every private practice pediatrician in the state. All of them were forced to move into hospital practice. In some cases the hospitals subsidized the practices to help keep them alive. Many pediatricians quit and left medicine in dismay.

You will have to forgive Doctors if they are skeptical about government involvement in medicine. Those of us who have been in health care long enough know that many of the problems medicine has today were created or accelerated with government "getting involved" and I personally am terrified at what is still to come.
Health Care is a complex issue. It cannot be solved without addressing all the underlying problems.
People expect the best care (all the latest high tech modalities) , delivered perfectly (no mistakes), with immediate results and free to them. Tell me please what business in this country delivers such a product? Patients in other countries have to wait, or have strict limits on what the country will and will not pay for, and the doctors cannot be sued. If Americans want to give up all the things they now demand, then I am sure the health care reform can happen. But realize this, since we can't afford the health care we are providing now, there will have to be limits ( same as if you were paying yourself) and there will have to be decisions made on what is cost effective to treat and what is not. This will not be popular. The seniors know this and that is why polls show them 44% opposed to the current form of reform. This is not a scare tactic, it is a fact that no politician wants to own up to.
Unless we have a serious non partisan discussion, we may pass a bill but we will not fix what's wrong.
Dr. D.S.

Reply #2 A British Perspective:
Hi, Ralph,
Haven't time to read through all this, but as someone who grew up with the British National Health System, I've been railing against the American insurance-company driven system for decades. The main problem here is that health care is a for-profit business. It should not be! The only real solution is a single-payer system that includes everyone, with no exclusions for pre-conditions, no deductibles and no paperwork. Hard to believe but that's what we have in Britain. Like Americans we have deductions taken from our paychecks to pay for our coverage. If you're not working, or retired, you're still covered anyway.
For all the touting of Medicare as the perfection solution here, as someone who is now on it I can tell you it has its shortcomings. Sure it's better than nothing but I'm still fighting over a bill that I believe should have been paid in full when my Medicare plan says it's part of my deductible.
Just the stress and effort involved in getting what you're entitled to makes you sick!
I'm with Rep. Weiner from New York who says single payer is the answer. But I don't expect for one minute we'll get it in my lifetime. Obama's plan, with the public option, will be an improvement on what we now have. There'll be no exclusions and some control over out-of-pocket costs. I'm not thrilled by it but will certainly take it for now.
Rita B.