bigjohn2441

OH SHIT!


seriously though, it shouldnt be a left/right issue (even though i think most left/right issues are bullshit), it should be common sense.

BVS

true dat

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MyBloodySleeve

martha

Real healthcare reform will only happen when a US Senator's child has a serious health crisis and his/her insurance won't cover it. Only when the loved ones of the powerful are treated like the rest of us will any real change happen.

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Skywheel
Skywheel Blog

deep

well,
that will never happen


more likely the blood sucking health profiteers,
will suck it dry,


much like the blood sucking wall street, finance, derivative profiteers did

then it will implode,

there won't any money in the system


then there will be a re-imagining of how we perceive health services, how they are delivered and how they are paid for.

Bluer White

America needs far more primary health care doctors. (Family doctors)

...The folks you see instead of emergency room$$$.


If we are short primary care docs today, and we are...

how will it look under Obamacare when we add another 40+ million to the rolls? Is there a plan out there to incentivize primary care versus lucrative medical $pecialties?

BVS

There are two reasons we have fewer primary care and internal medicine doctors.

a. People put off physicals, and then go to emergency rooms when their ignored health becomes a problem.

b. Insurance companies. IM and primary health just don't get paid anymore so why go into the field? Insurance companies being that their priority is profit and not health don't reimburse shit for IM and primary health. A lot of IM are changing specialties.

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yolland

The Economist cover story, June 25


...The American health-care system, which gobbles up about 16% of the country’s economic output, is by far the most expensive in the world (see chart 1). The Congressional Budget Office (CBO) estimates that on current trends spending on Medicare and Medicaid, the government schemes for the old and the poor, will rise from 4% of GDP in 2007 to 12% in 2050. The prospect of long-term fiscal disaster is the main reason why efforts to reform health care are gaining momentum in Washington, DC. As Peter Orszag, the director of Barack Obama’s Office of Management and Budget, puts it, “that ‘long term’ keeps getting closer and closer.”

The system has its defenders. They point out that countries should expect to spend more on health care as people age. Americans are wealthy enough to choose extra health care over other things. Their free-spending approach calls forth the invention and speedy adoption of valuable new drugs, devices and procedures, whereas Europe’s stodgy and stingy (not to mention socialist) health-care systems deny coverage and ration care, to the detriment of their people’s health.

A poll carried out for The Economist by YouGov highlights Americans’ beliefs about the state of their system. Although 68% of them rate the care they receive as “excellent” or “good”, 52% are dissatisfied with the quality in the country as a whole. Only 25% think the system works pretty well and requires only minor changes; 40% think fundamental change is needed and 29% think it should be completely rebuilt.

The doubters have a better case than the defenders. Granted, medical inventions are readily embraced by American doctors and patients. In specific instances—technology to save babies born prematurely and statin drugs to reduce cholesterol, to take two—the benefits of spending greatly outweigh the costs. But if the system in general were providing value for money, America’s vast expenditure would at least be reflected in a healthier population than in more frugal countries. Alas, it is not. Comparisons with other rich countries and within the United States show that America’s health-care system is not only growing at an unsustainable pace, but also provides questionable value for money and dubious medical care. Three troubling symptoms stand out: uneven quality of care, inadequate coverage and soaring costs.

Start with quality. Evidence is mounting that spending more does not necessarily buy better health. On the contrary, it appears that many Americans are getting mixed or even downright dreadful health care. In a recent study economists at the OECD found that America does indeed do well on some measures, such as breast-cancer survival rates and cervical-cancer screening, compared with other rich countries. However, it does worse in other areas. American infant mortality was 6.7 per 1,000 births in 2007, against an OECD average (excluding Mexico and Turkey) of 4.0. The death rate after haemorrhagic strokes was 25.5% in American hospitals but only 19.8% in OECD countries as a group.

...The Dartmouth Atlas project has scrutinised variations in health outcomes and spending involving Medicare. It has found wide differences in costs across the country—less than $5000 per person in Salem, Oregon, in 2006; a bit more than $8000 in San Francisco, in line with the national average; more than $16,000, and rising fast, in Miami—but no connection between higher spending and better outcomes. In fact, the evidence points in the other direction: outcomes tend to be better where costs are lower. Mr Orszag points to the Dartmouth work to argue that up to 30% of America’s health-care spending is sheer waste.

The second symptom is coverage. Uniquely among rich countries, America’s system of health insurance is not universal. Around 49m people have no health insurance. On current trends, within a decade 60m will be without cover. Studies have shown that not all these people are indigent: a quarter or more can afford insurance, but choose not to buy it. They know they are unlikely to be left to die in the streets. With the truly poor, the free-riders turn up at emergency rooms. This is hugely inefficient, because pricey late interventions and operations could very often have been avoided with a much smaller investment in preventive care. Insured people and taxpayers are forced to cross-subsidise such “uncompensated” and wasteful treatments to the tune of tens of billions of dollars per year.

Other rich countries cover almost all their citizens in one of two ways. Some, such as Britain, Canada and Sweden, have “single payer” systems, in which taxes support a public service. Others, notably the Netherlands and Switzerland, oblige individuals to buy insurance. France has a mixed public-private system.

After decades of failed attempts at reform, a consensus appears to be emerging in America around the principles needed for universal coverage. One likely change means a restructuring of America’s failed health-insurance markets. Firms are today allowed to pick the safest patients and reject the sickest. In future they will have to take all comers. Because this imposes unfair burdens on firms that attract lots of older or sicker people, reform is likely to include government-funded mechanisms for risk pooling or reinsurance. The Netherlands, in particular, uses such an approach.

American health insurers, having long opposed this idea, have performed a startling U-turn in recent weeks. America’s Health Insurance Plans, their chief lobbying group, now says it is willing to accept such heavy-handed reforms—if they are accompanied by a requirement that all Americans purchase coverage. This may seem a cynical ploy to expand their business, but some compulsion is needed to get around the selection problem. Any legislation is likely to include subsidies to help the poorest pay for cover. If done properly, this will in time move America towards the Swiss and Dutch models of universal private insurance. These are not perfect, to be sure. Regina Herzlinger of Harvard Business School observes that the Dutch reforms have led to rapid consolidation of insurers and hospitals, fuelling resented price increases. She favours the decentralised Swiss model, which preserves individual choice and competition. Others note that Swiss health-care costs are high by European standards. But they are a third less, as a share of GDP, than America’s, and the country’s excellent health outcomes should be the envy of American reformers. Our poll suggests that an individual mandate would be unpopular, with only 21% in favour and 53% opposed. Respondents did favour having the option to buy from the government, by 56% to 23%.

Such reforms would expand coverage, but could exacerbate the third symptom, cost, as the experience of Massachusetts, a trailblazing state that has already implemented a plan for universal coverage, suggests. The state faces possible bankruptcy unless it finds a way to rein in costs. Indeed, tackling inflation in American health care remains the most important and difficult part of the treatment. According to our poll, cost is a tender nerve: 61% thought the high cost of care and insurance was a bigger problem than the number of uninsured, against 31% who believed the reverse. Only 21% would be willing to support a reform plan if they had to pay more in insurance or tax; 62% would not.

Some common diagnoses are wide of the mark. One is price gouging by drug companies. In fact, pills account for barely a tenth of health-care spending in America and similarly small shares elsewhere. But aren’t costs lower in Europe because of price controls? Europe does indeed spend less on new branded drugs, but also uses fewer generic drugs and pays much more for them. And Switzerland actually has higher drug prices than America (as does Canada). Greedy drugmakers are not the main cause of America’s runaway costs. Nor are baby-boomers, though they are often blamed for health-care inflation because there are a lot of them and they are getting old. Ageing will clearly push up costs in time (see our special report in this issue), but it is not the main culprit yet. The CBO estimates that ageing accounts for only a quarter of the health-care inflation to come in the next few decades, and the share in other rich countries is similar.

Doctors’ generous pay is another popular culprit. But doctors in several European countries are well paid too. The OECD estimates that general practitioners in America earn 3.7 times the average wage. Their British counterparts earn 4.2 times their national average. American specialists earn 5.6 times the average wage, against 7.6 times for their Dutch colleagues. Yet health-care costs in Britain and the Netherlands remain lower than America’s. The real problem is not how much American doctors are paid, but how. The system of medical reimbursement warps incentives for doctors, insurers and patients that lead Americans to consume more and more medical services. There is strong evidence that Americans use pills, procedures, scans and other expensive forms of health care more often than do patients in other rich countries, and not always to good effect.

America’s insurance system encourages overuse in several ways. One is the tax break that favours health insurance provided by employers, which leads to excessively generous coverage and hence over-consumption. Another is the fact that American health insurers earn a lot of revenue from administering the health plans provided to employees by big corporations which, in effect, insure themselves. This leaves insurers with no incentive to curb costs, because more spending means fatter management fees. The incentives facing doctors are even more perverse. Most doctors are not paid a fixed salary, still less rewarded for better health outcomes. Integrated American systems such as Kaiser Permanente and the Mayo Clinic are exceptions to this rule, and Britain’s National Health Service (NHS) is trying to adopt a similar approach. But most doctors and hospitals are paid more if they provide more services, regardless of the results. Predictably, this leads to far higher rates of doctors’ visits, specialist referrals, scans and so on. For instance, the OECD countries have an average of 11 magnetic-resonance imaging machines per 1m people. America has 25.9. America uses them more often, too: 91.2 times per 1,000 people per year, compared with the OECD average of 39.1. Similar tales can be told about other pricey kit.

This incentive problem even extends to patients. If patients pay very little out of their own pockets they have little desire to curb consumption. Though this is a problem in many OECD countries, in America the proportion of out-of-pocket spending has declined sharply in the past few decades. And a new report by McKinsey, a firm of management consultants, identifies a more subtle problem. Having examined insurance and out-of-pocket spending for several health risks, it concludes that Americans are generally “over-insured and under-saved”. It is prudent for individuals to have comprehensive health insurance against catastrophic health risks such as heart attacks or cancer. But McKinsey finds that Americans with private health insurance often have generous coverage for non-essential and even medically unjustified care (see chart 3). This encourages over-consumption.

A second big factor pushing up health costs is the lack of competition among operators of American hospitals. Thanks to a wave of consolidation in recent years, argues Harvard’s Ms Herzlinger, “most parts of the United States are dominated by oligopolistic hospital systems.” George Halvorson, who heads Kaiser Permanente, insists that “there is an almost total lack of price competition among providers.” Nimble upstarts and innovators are challenging the incumbents in some areas. Such efforts range from specialist heart hospitals, which get better outcomes at more reasonable prices than local general hospitals, to retail clinics at Wal-Mart stores. Remote medicine, in the form of technology for tele-care or medical tourism to Thailand and Costa Rica, also poses a threat. But medical lobbies are using political influence and outdated regulations to thwart competition where they can (for example, through rules preventing a doctor from treating a patient in another state). To counter this, reforms could allow federal regulators to overrule state-level obstacles to entrants such as clinics staffed by inexpensive nurse-practitioners. More transparency would help too, by empowering patients to choose hospitals and doctors providing good value and better results. Electronic medical records would make shopping around easier.

Another useful way to promote transparency and value would be to evaluate the cost-effectiveness of new drugs, devices and treatments. This may be common sense, but it is rarely done in America. Britain’s National Institute for Health and Clinical Excellence (NICE) pioneered this approach, and other European countries have followed it. Andrew Dillon, the agency’s chief executive, accepts that “the NICE model is not transportable in precise form” but he still insists that “one can dissect and apply what is relevant to other countries.” In America, the drugs and devices lobbies are violently opposed to a NICE-style agency that could issue mandatory rulings. They paint a scary picture of Americans being denied access to life-saving new drugs by faceless bureaucrats. In Britain NICE has come under fire for rulings that limited access to expensive drugs for Alzheimer’s and cancer on the NHS. America could get around this problem by requiring and perhaps even funding studies, but leaving insurers and individuals to decide whether to pay for treatments.

More competition and transparency would help, but the main goal of any reform plan must be to address the perverse incentives that encourage overconsumption and drive up costs. Medicare has been tinkering with “pay for performance”, a promising experiment. Mr Halvorson insists that by rejigging incentives other health providers can also create their own “virtual Kaisers”. If American reformers doubt the power of incentives, they should visit Sweden. Like other relatively cheap OECD systems, Sweden’s single-payer model has been plagued by long waiting-lists—a sign, to American conservatives, of the rationing that goes with socialised medicine. Swedish health officials tried and failed to cut queues by increasing direct funding for hospitals and even issued an edict requiring hospitals to cut queues for elective operations to three months. Then, last year, the health ministry said it would create a fund into which it would pay SKr1 billion ($128m) a year for local authorities that managed to reduce waiting times to that threshold. Nine months ago virtually none of the counties passed, but this month the health minister revealed that nearly all had cut their queues to three months or less. Anders Knape, the head of the organisation representing county governments, ascribes this to “a dramatic change in incentives”. In the past, he explains, hospital bosses believed waiting lists were a sign of being overloaded, so they tolerated them in the hope of winning more funding. With the new scheme, however, “no queues means more resources”.

If getting incentives right can mobilise even a state-run health system like Sweden’s, surely there is scope for such reforms to fix America’s mess too. If the United States couples its efforts to expand coverage with such a radical restructuring of the underlying drivers of cost inflation, there is every reason to think its health system can become the best in the world—and not merely the priciest.

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MrsSpringsteen

That would never happen because they have the best health insurance around (from what I understand), and even if they didn't they're powerful and public and the insurance company would behave accordingly.

MA has mandatory health insurance, of course now they're struggling to pay for the subsidized type for the poor and the paid type just continues to go up in cost just like all health insurance does. It was pushed by Romney, a Republican gov who just happened to intend to run for President. I guess that was just a coinkydink.

melon

Frankly, what ails the U.S. health care system is that, even in its current, privatized form, it bears no resemblence whatsoever to the classical formula of capitalism, and health insurance, by definition, just exacerbates the problem. Health insurance sure solved the original problem of what to do when you couldn't afford to pay for health care out-of-pocket, but it couldn't anticipate what would happen when the insurance, itself, would become too expensive in the face of downright astronomical charges.

Merely forcing people to have health insurance is basically nothing more than trying to prolong the inevitable. Sure, if you forced everyone to have health insurance, it would temporarily increase the pool of funds, but additional funds will only serve to push our non-competitive "suppliers" (doctors, hospitals, etc.) to charge more, because they can. And then we'll be right back to square one.

There's only two options that would work, and that would require either a hardline free-market or governmental solution:

1) Switch to government-funded health care, coupled with a regulatory framework that limits how much doctors and hospitals can charge. Considering that our current health-care system bears little-to-no resemblence to a functional capitalist framework, at least we can just abandon all pretense and regulate it effectively.

2) Ban health insurance altogether, and let the market determine the value of health care--which, frankly, would decimate our current, overpriced system and bring the value of everything--doctors, hospitals, treatments, medicine, etc.--down to what "the market"--i.e., patients--can bear.

#2, however, is grossly impractical, mainly due to the fact that the economy is global, and doctors would just flee to other nations abroad where they would get paid more.

I'm not sure how we can realistically avoid the fact that #1 is where the future lies. Health care has already long ceased to resemble capitalism, and we might as well just suck it up and admit it. Otherwise, we're just going to waste even more money on a failing system.

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melon

I'm not sure what they're asking for here. Do they want patients to forego going to the doctor when they are sick? If we're talking medically unnecessary treatments (thus resources are being wasted), would this not be a failure of doctors instead to stop their patients from pursuing needless medical care?

I certainly know of more than a few doctors who see their elderly patients as "cash cows," and most certainly encourage them to engage in exorbitant consumption. My old family doctor was the only one I had ever heard tell my grandmother that she didn't need all those prescriptions from her old doctors and that she should stop taking them, along with telling her that the "specialists" she had been seeing for various perceived ailments over the years were completely unnecessary. How come there aren't more doctors like this?

If doctors said "no" more often, then patients wouldn't "overconsume." We cannot expect people to actively know what "consumption" is appropriate or not, and merely curtailing consumption by driving poor people away is morally repugnant.

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yolland

I took that quote as a somewhat-of-an-aside corollary re: the "perverse incentives" for doctors to prescribe wastefully unnecessary 'treatments,' and for insurers to keep covering them, already mentioned. In other words, if you're someone with "good" insurance, then--depending on both your current health and your doctor's integrity (and to be fair, his/her awareness of your medical history)--you might wind up in the position of getting all kinds of wastefully unnecessary treatments, basically for free. And yes, that's ultimately the doctor's responsibility, but if you were footing a bit more of the bill, then you'd probably start asking more questions like, "Hold on a minute--Dr. ____ already recently tested me for that, and everything came back negative; why do we need to do it again now?"

You're right though about the absurdity of expecting patients to take much responsibility for "overconsumption"; medical care isn't just another 'product,' where any layperson can easily make him/herself a 'highly informed consumer.'

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melon

And, frankly, we've seen what happens when HMOs take charge of what's "medically necessary" too. Patients who need procedures that are deemed medically necessary by their doctors are sometimes rejected likely just because they're "too expensive."

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jimyjazz

The best countries to live in all have universal, communist healthcare...it's cheaper and more equitable.

Why would America want to emulate Denmark, Sweden, Canada...?

AliEnvy

Yep. Not sure if this latest faux pas has made into any thread around here.

'The Select Few' Are Cashing in: Shocking Corruption at the Washington Post

by Bill Moyers and Michael Winship
.
Global Research, July 15, 2009

If you want to know what really matters in Washington, don't go to Capitol Hill for one of those hearings, or pay attention to those staged White House "town meetings." They're just for show. What really happens -- the serious business of Washington -- happens in the shadows, out of sight, off the record. Only occasionally -- and usually only because someone high up stumbles -- do we get a glimpse of just how pervasive the corruption has become.

Case in point: Katharine Weymouth, the publisher of The Washington Post -- one of the most powerful people in DC -- invited top officials from the White House, the Cabinet and Congress to her home for an intimate, off-the-record dinner to discuss health care reform with some of her reporters and editors covering the story.

But CEOs and lobbyists from the health care industry were invited, too, provided they forked over $25,000 a head -- or up to a quarter of a million if they want to sponsor a whole series of these cozy get-togethers. And what is the inducement offered? Nothing less, the invitation read, than "an exclusive opportunity to participate in the health-care reform debate among the select few who will get it done."

The invitation reminds the CEO's and lobbyists that they will be buying access to "those powerful few in business and policy making who are forwarding, legislating and reporting on the issues...

"Spirited? Yes. Confrontational? No." The invitation promises this private, intimate and off-the-record dinner is an extension "of The Washington Post brand of journalistic inquiry into the issues, a unique opportunity for stakeholders to hear and be heard."

Let that sink in. In this case, the "stakeholders" in health care reform do not include the rabble -- the folks across the country who actually need quality health care but can't afford it. If any of them showed up at the kitchen door on the night of this little soiree, the bouncer would drop kick them beyond the Beltway.

Now, before you can cross the threshold to reach "the select few who will actually get it done," you must first cross the palm of some outstretched hand. The Washington Post dinner was canceled after a copy of the invite was leaked to the web site Politico.com, by a health care lobbyist, of all people. The paper said it was a misunderstanding -- the document was a draft that had been mailed out prematurely by its marketing department. There's noblesse oblige for you -- blame it on the hired help.

In any case, it was enough to give us a glimpse into how things really work in Washington -- a clear insight into why there is such a great disconnect between democracy and government today, between Washington and the rest of the country.

According to one poll after another, a majority of Americans not only want a public option in health care, they also think that growing inequality is bad for the country, that corporations have too much power over policy, that money in politics is the root of all evil, that working families and poor communities need and deserve public support if the market system fails to generate shared prosperity.

But when the insiders in Washington have finished tearing worthy intentions apart and devouring flesh from bone, none of these reforms happen. "Oh," they say, "it's all about compromise. All in the nature of the give-and-take-negotiating of a representative democracy."

That, people, is bull -- the basic nutrient of Washington's high and mighty.

It's not about compromise. It's not about what the public wants. It's about money -- the golden ticket to "the select few who actually get it done."

When Congress passed the Helping Families Save Their Homes Act, "the select few" made sure it no longer contained the cramdown provision that would have allowed judges to readjust mortgages. The one provision that would have helped homeowners the most was removed in favor of an industry that pours hundreds of millions into political campaigns.

So, too, with a bill designed to protect us from terrorist attacks on chemical plants. With "the select few" dictating marching orders, hundreds of factories are being exempted from measures that would make them spend money to prevent the release of toxic clouds that could kill hundreds of thousands.

Everyone knows the credit ratings agencies were co-conspirators with Wall Street in the shameful wilding that brought on the financial meltdown. But when the Obama administration came up with new reforms to prevent another crisis, the credit ratings agencies were given a pass. They'd been excused by "the select few who actually get it done."

And by the time an energy bill emerged from the House of Representatives the other day, "the select few who actually get it done" had given away billions of dollars worth of emission permits and offsets. As The New York Times reported, while the legislation worked its way to the House floor, "It grew fat with compromises, carve-outs, concessions and out-and-out gifts," expanding from 648 pages to 1400 as it spread its largesse among big oil and gas, utility companies and agribusiness.

This week, the public interest groups Common Cause and the Center for Responsive Politics reported that, "According to lobby disclosure reports, 34 energy companies registered in the first quarter of 2009 to lobby Congress around the American Clean Energy and Security Act of 2009. This group of companies spent a total of $23.7 million -- or $260,000 a day -- lobbying members of Congress in January, February and March.

"Many of these same companies also made large contributions to the members of the Senate Environment and Public Works Committee, which has jurisdiction over the legislation and held a hearing this week on the proposed 'cap and trade' system energy companies are fighting. Data shows oil and gas companies, mining companies and electric utilities combined have given more than $2 million just to the 19 members of the Senate Environment and Public Works Committee since 2007, the start of the last full election cycle."

It's happening to health care as well. Even the pro-business magazine The Economist says America has the worst system in the developed world, controlled by executives who are not held to account and investors whose primary goal is raising share price and increasing profit -- while wasting $450 billion dollars in redundant administrative costs and leaving nearly 50 million uninsured.

Enter "the select few who actually get it done." Three out of four of the big health care firms lobbying on Capitol Hill have former members of Congress or government staff members on the payroll -- more than 350 of them -- and they're all fighting hard to prevent a public option, at a rate in excess of $1.4 million a day.

Health care policy has become insider heaven. Even Nancy-Ann DeParle, the White House health reform director, served on the boards of several major health care corporations.

President Obama has pushed hard for a public option but many fear he's wavering, and just this week his chief of staff Rahm Emanuel -- the insider di tutti insiders -- indicated that a public plan just might be negotiable, ready for reengineering, no doubt, by "the select few who actually get it done."

That's how it works. And it works that way because we let it. The game goes on and the insiders keep dealing themselves winning hands. Nothing will change -- nothing -- until the money lenders are tossed out of the temple, the ATM's are wrested from the marble halls, and we tear down the sign they've placed on government -- the one that reads, "For Sale."

yolland

^ I thought about that story when I posted the David Brooks clip, actually. He was considering Washington's 'loss of dignity' on a different front, but to a point I think there's a common theme there, corruption resulting from relentless self-marketing and self-commodification.

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