Author: cmh

FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung-mei cheng | PBS

FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung–mei cheng PBS

Wow. I can’t say enough about this interview. It is so on the mark in so many ways, and it is a pleasure to hear knowledgeable people discuss comparative international healthcare like this.

There are great bits on the real meanings of “socialized” medicine, vs socialized insurance, the German (!) perspective on the dignity of every person, the Canadian perspective on humanism, the leadership of Tony Blair turning around a system on the rocks, how terrifically well America does in training its healthcare providers (especially doctors), but the best is Reinhardt’s take on “Consumer Driven Healthcare“, quoted here:

We’ve heard some people have proposed that a solution for America is something called consumer-driven health care. How does it work? What is it?

… Well, the name “consumer-driven health care” at this time is a deceptive marketing label. What we’re really talking about is an insurance policy with a very high annual deductible — up to $10,500 per family, and less for an individual — and then coupled with a savings account into which you can put money out of pretax income; you don’t have to pay taxes on such income.

Now, this has the advantage … that people faced with this deductible will think twice before going to the doctor for trivial issues or drugs they don’t need, etc. But of course the problem also is that they may not go when they should or may skimp on the drugs they should be using, like a blood pressure drug, so that one would have to be solved by saying preventive services will have first-dollar coverage. So you could solve that problem.

But then what I argue is, yes, it may have the economic effect of cost control, because you then would have to know the prices different doctors charge, and hospitals and pharmacies, and something about the quality. And that information at this time exists only in a few areas. The insurance companies are beginning to work on Web sites that will give you that, but it’s still very primitive and fairly unreliable information. So that is why I compare it really more like thrusting someone into Macy’s department store blindfolded and say, “Go around; shop smartly.” …

The other problem that I see with it, though, is it has ethical dimensions to it that people don’t appreciate. If I make anything tax-deductible, then a high-income person in a high tax bracket saves more than a poor [person]. So supposing a gas station attendant and I each put $2,000 into a health savings account, and we get a root canal — about $1,000, just the drilling. It costs me about $550 because I’m in the 45 percent bracket. The gas station attendant may, in fact, not pay federal income tax because the income is so low but may only pay Social Security, so he saves 8 cents on the dollar. So a root canal will cost me $550; will cost him $920. …

Secondly, think of a family of two professionals, each making $140,000, close to $300,000 income, and they have, say, a $5,000 deductible. Would they deny their child anything that they think the child needs over a lousy $5,000? … But think of a waitress who makes $25,000 with a $5,000 deductible, and her kid is sick. It will certainly make her think twice. She’s likely to say, “Maybe not.” So therefore we’re asking the lower half of the income distribution to do all the self-rationing through prices. …

And the third issue is this deductible. If you’re chronically healthy, you don’t actually ever spend as much as that; you have a tax-free savings account. If you are chronically ill, on five drugs, you’re going to spend that deductible year after year. So the proposal is to shift more of the financial burden of health care from the shoulders of the chronically healthy to the shoulders of the chronically sick.

And I would say, imagine a politician coming to the people with a platform that I just described in ethical terms. … You think that would sell? So they say, “We’ve got to find a better name. Why don’t we call it consumer-driven health care?,” and have all these deceptive labels that even George Orwell wouldn’t have thought of. That is what I find troublesome. Yes, it’s an approach to health care, but could you please describe it to the American people honestly, in all of its dimensions — not just economics but information and ethics? And that’s not done. …

One answer he gave about physicians income left me with more questions that when I started:

Yes, American doctors get paid more, relative to average employees, than doctors in other nations; that is true. It’s about five times average employee compensation, and in England it’s about two, and in Canada it’s about three. So that’s certainly true.

Given the unprecedented income disparity in this country, it is hard to know what to make of these figures. Comparison to the median would have been more helpful, but I think the most interesting would be to see in which decile physicians place in each country. I will try to find that data.

This Frontline Website is a gold mine. Thanks to the indispensable CPB.

FRONTLINE: sick around the world: five capitalist democracies & how they do it | PBS

FRONTLINE: sick around the world: five capitalist democracies & how they do it PBS:

“Each has a health care system that delivers health care for everyone — but with remarkable differences.”

Summaries of the five countries covered in the Frontline episode: UK, Germany, Japan, Taiwan and Switzerland.

Frontline: Sick Around the World

Frontline: Sick Around the World

Lots to digest, and I’ve only begun to explore the web extras, so I post now for convenience’ sake. Overall, though, TR Reid did a terrific job all around.

From the physicians’ perspective, I, of course would have liked more but they only chose to do an hour. Frankly, this would have been another good use of an extended format Frontline, as they did with “Bush’s War.”

Rent hikes forcing out city (Calgary, Canada) doctors

Rent hikes forcing out city doctors:

“‘It’s scary,’ said Dr. Linda Slocombe, president of the Calgary and Area Physicians’ Association, who notes that doctors, unlike most other small businesses, can’t raise their prices to offset rising costs. ‘In another two or three years we’re going to have a real drastic shortage of family doctors.’

The study, which was commissioned by CHR last summer but only became public during a recent meeting of Calgary family physicians, comes as the city already struggles with a doctor shortage.

An estimated 200,000 Calgarians don’t have a regular family physician, a problem that has been compounded by at least 41 doctors who have closed their practice in recent years.

Experts say the physicians are retiring or leaving to pursue other jobs in medicine, where they earn a good salary and don’t have the hassle of operating an office.”

Posting this in keeping with my “warts and all” policy of reporting the good and the bad of other systems.

BUT, does any of this not apply to PCP’s in America? Can’t raise our prices? The hassle of operating an office? (And they don’t even have to deal with dozens of private health insurers, so they are mainly talking about the other hassles.)

Cheers

AMNews: April 21, 2008. More physicians backing national coverage — study … American Medical News

AMNews: April 21, 2008. More physicians backing national coverage:

“Physicians who support ‘government legislation to establish national health insurance’
————————-2002————-2007
All specialties————49%————–59%
Psychiatry—————64%————–83%
Pediatric subspecialties—71%————–71%
Emergency medicine—–53%————–69%
Pediatrics—————-64%————–65%
Internal medicine——–56%————–64%
Medical subspecialties—-50%————–63%
Pathology—————-n/a—————60%
Family medicine———-44%————–60%
Ob-gyn——————-48%————–58%
General surgery———-52%————–55%
Surgical subspecialties—-37%————–45%
Anesthesiology———–35%————–39%
Radiology—————-n/a—————30%

I will try to get more of the details to the original article from the April 1 Annals of Internal Medicine tomorrow, as I can’t access it here at home tonight.

Update: here is the link to the Annals page. Actually not much more info there but here is the full results summary:

Results: Of 5000 mailed surveys, 509 were returned as undeliverable and 197 were returned by physicians who were no longer practicing. We received 2193 surveys from the 4294 eligible participants, for a response rate of 51%. Respondents did not differ significantly from nonrespondents in sex, age, doctoral degree type, or specialty. A total of 59% supported legislation to establish national health insurance (28% “strongly” and 31% “generally” supported), 9% were neutral on the topic, and 32% opposed it (17% “strongly” and 15% “generally” opposed). A total of 55% supported achieving universal coverage through more incremental reform (14% “strongly” and 41% “generally” supported), 21% were neutral on the topic, and 25% opposed incremental reform (14% “strongly” and 10% “generally” opposed). A total of 14% of physicians were opposed to national health insurance but supported more incremental reforms. More than one half of the respondents from every medical specialty supported national health insurance legislation, with the exception of respondents in surgical subspecialties, anesthesiologists, and radiologists. Current overall support (59%) increased by 10 percentage points since 2002 (49%). Support increased in every subspecialty since 2002, with the exception of pediatric subspecialists, who were highly supportive in both surveys.

The spin in the AMA News article is predictable (poorly worded survey questions), and, OK, fine, maybe some didn’t mean exactly as they answered. We’ve all taken surveys, and it is true, you can only answer the question that is asked.

But look at some of these numbers because they are astounding. When 45% of physicians in surgical subspecialties (we’re talking orthopods, urologists, and neurosurgeons here!) and 55% (!!!!) of general surgeons answer this way, there is a problem.

AMA Policy is against single payer. But AMA policy is determined by it’s House of Delegates. This is a very democratically structured body, but frankly, delegates are far older and more conservative than all other AMA members and AMA members are older and more conservative than physicians as a whole, so this is a problem that will take a leader from within the AMA leadership to take up and champion. Which, knowing the culture a bit, would be courageous, but history making.

Putting this together with the Minnesota and Jackson and Coker surveys, we may finally be acheiving critical mass.

Jackson and Coker Physician Survey on “Universal Healthcare”

Survey details:

“As a result, Jackson & Coker commissioned a survey to determine the opinions of health professionals, especially practicing physicians, on the topic of healthcare reform. The survey results convey their views and advance the ongoing debate at this point in the presidential election cycle.”

Jackson and Coker is a physician recruiting firm. I actually got an e-vite to this survey and took it. Most respondents were in practice 15 years or longer, making them likely significantly more Republican and “conservative,” so take it with a tablespoon of salt.

I frankly didn’t find many surprises in it, much like surveys done by “The Factor” or Lou Dobbs, but I did find a ray of hope in the morass:

When asked, “Should health insurance be controlled by the government or private companies?”
25% said “The Federal Government” and 39% said “Private companies with government oversight.”

That gives a surpisingly large (can I say overwhelming?) 64% majority in this survey who sound like they would accept a Single Payer system in the sense of something like a Medicare-for-All system of government contracted payers.

Wow. The seeds are there.

CITY HEALTH CLINICS NEED A BOOSTER SHOT | Philadelphia Daily News | 04/04/2008

CITY HEALTH CLINICS NEED A BOOSTER SHOT Philadelphia Daily News 04/04/2008:

“How they don’t work: The system is far from perfect. According to a report released by the Philadelphia Unemployment Project last year, it can take up to five months to schedule an appointment with a doctor at a health center. Advocates say the centers need to extend evening hours and add staff to shorten waiting times. The mayor’s proposed funding increase is supposed to deal with some of these issues.
One of the biggest challenges that health centers face is offering competitive salaries to attract qualified staff.

The salaries offered by the city for three critical positions – pharmacists, dentists and physicians – are relatively low when compared to industry averages.

The highest-paid pharmacist working for the city makes $77,013 – well below the national median of $103,000. The same is true for dentists who work for the city. A typical dentist makes $130,000 a year. That’s significantly more than the $95,630 made by the highest-paid dentists at city health centers.

The largest discrepancy can found in the salary paid to doctors. The average physician working in a family practice makes $204,000. The highest-paid physician working for the city makes $109,820 – a difference of more that $94,000.”

Just had to post this for all of those who insist we don’t have to wait for healthcare in America and that “everyoine in America has access to health care.”

Drawing Lots for Health Care -[Oregon] New York Times

Drawing Lots for Health Care – New York Times:

“Last month, right after he had the heart attack and then the heart surgery and then started receiving the medical bills that so far have topped $200,000, Melvin Tsosies joined the 91,000 other residents of Oregon who had signed up for a lottery that provides health insurance to people who lack it.

Melvin Tsosies is among Oregonians who signed up for a health insurance lottery. “They said they’re going to draw names, and if I’m on that list, then I’ll get health care,” said Mr. Tsosies, 58, a handyman here in booming Deschutes County. “So I’m just waiting right now.”

Despite the great hopes of people like Mr. Tsosies, only a few thousand of Oregon’s 600,000 uninsured residents are likely to benefit from the lottery anytime soon. The program has only enough money to pay for about 24,000 people, and at least 17,000 slots are already filled.”

further down…

“Oregon once sought to serve a far larger population of those in need.
It has been more than a decade since the innovative Oregon Health Plan became a forerunner of state health care reform as it pursued universal health coverage. Conceived on a restaurant napkin in the late 1980s, the program had by 1996 reduced the number of the uninsured to about 11 percent of all residents, down from more than 18 percent in 1992. But then, early in this decade, the state endured a wrenching recession.
“Oregon was way ahead of everyone else,” said Charla DeHate, the interim executive director of Ochoco Health Systems. “And then we went broke.” “

Top o’ the world, Ma!

Most Republicans Think the U.S. Health Care System is the Best in the World. Democrats Disagree. – March 20, 2008 -2008 Releases – Press Releases – Harvard School of Public Health

Most Republicans Think the U.S. Health Care System is the Best in the World. Democrats Disagree. – March 20, 2008 -2008 Releases – Press Releases – Harvard School of Public Health:

“A recent survey by the Harvard School of Public Health (HSPH) and Harris Interactive, as part of their ongoing series, Debating Health: Election 2008, finds that Americans are generally split on the issue of whether the United States has the best health care system in the world (45% believe the U.S. has the best system; 39% believe other countries have better systems; 15% don’t know or refused to answer) and that there is a significant divide along party lines. Nearly seven-in-ten Republicans (68%) believe the U.S. health care system is the best in the world, compared to just three in ten (32%) Democrats and four in ten (40%) Independents who feel the same way.”

The survey results are here.

New Focus of Inquiry Into Bribes: Doctors – New York Times

New Focus of Inquiry Into Bribes: Doctors – New York Times:

“Once companies begin to develop the devices, leading doctors are hired as consultants to help modify the implants and related hardware. When the products are finally brought to market, companies also hire many of the same opinion leaders to train other doctors and sales representatives how to use them.

As a result, Mr. Christie has had no problem finding large sums of money — in some cases, more than $1 million annually — flowing from companies to doctors who use their devices. But doctors say it is far too simplistic to conclude, as Mr. Christie claimed last fall, that “many orthopedic surgeons in this country made decisions predicated on how much money they could make — choosing which device to implant by going to the highest bidder.”

For the most part, the hip and knee joints sold by the major companies are similar in performance, but getting surgeons to switch is a lot more difficult than persuading an internist to prescribe a prescription drug rather than aspirin.”