Category: Uwe Reinhardt

This American Life HC Reform Part 2

This American Life:

This week, we bring you a deeper look inside the health insurance industry. The dark side of prescription drug coupons. A story about Pet Health Insurance, which is in its infancy, and how it is changing human behaviors—for example, if you have the pet health insurance, you bring your pet to the vet more often, and the vet makes more money and…well, you can see the parallels. And insurance company jargon, frighteningly decoded.

Prologue. Host Ira Glass describes the crazy world of medical billing, where armies of coders use several contradictory different systems of codes…and none of it makes us healthier. (5 minutes)

Act One. One Pill Two Pill, Red Pill Blue Pill.
Planet Money’s Chana Joffe-Walt explains why prescription drug coupons could actually be increasing how much we pay, and prevent us from even telling how much drugs cost. (13 1/2 minutes)

Act Two. Let’s Take Your Medical History.
Alex Blumberg and Adam Davidson recount how four accidental steps led to enacting the very questionable system of employers paying for health care. (11 1/2 minutes)

Act Three. Insurance? Ruh Roh!
Planet Money correspondent David Kestenbaum investigates the growing popularity of pet
insurance, and what it reveals about insurance for people. (14 minutes )

Act Four. Sorry Johnny… It’s Only Business.
This American Life producer Sarah Koenig reports on a very surprising reason why insurance companies dump members, and how this reasoning contradicts President Obama’s argument for what will lower health care costs. (11 1/2 minutes)

Again, a very interesting program to follow up on last week’s episode.

In Act IV, the interview with Uwe Reinhardt is very thought provoking. Specifically, he talks about the power of suppliers (i.e., hospitals) in the insurer-provider tug of war, and about Maryland’s “All Payer System,” which I will try to learn more about and pass along when I do…

MP3 of Part 2

MP3 of Part 1 is not offered directly at the website. You can subscribe to the podcast and then download yourself here: http://feeds.thisamericanlife.org/talpodcast

“Common Sense” Health Care Reform Principles

Uwe Reinhardt Economix Blog

The All-American Wish List for Health Reform

  1. Only patients and their own doctors should decide what clinical response is appropriate for a given medical condition, even if that response involves
    unproven clinical procedures or technology.
  2. Neither government bureaucrats nor private insurance bureaucrats should ever refuse to pay for whatever patients and their doctors have decided to do in response to a given medical condition. An insurer’s refusal to pay for a medical procedure is tantamount to rationing health care.
  3. Rationing health care is un-American.
  4. Cost-effectiveness analysis should never be the basis of any coverage decision by public or private third-party payers in health care, for to do so would put a price on human life — which, in America, unlike everywhere else, is priceless.
  5. Government should not require individuals to purchase health insurance. Such a mandate would violate the constitutional rights of freedom-loving Americans.
  6. Americans have a moral right to life-saving and potentially highly expensive medical care, should they fall critically ill, even if they are uninsured and could not possibly pay for that care with their own financial resources. (Why else would God have created hospitals and their emergency rooms?)
  7. Government should stay out of health care. Specifically, government should not control health care prices, nor should it increase its spending on health care, which is out of control.
  8. Even small reductions to the future growth of Medicare spending — called “cuts” in Washington parlance — unfairly burden the elderly, along with the
    doctors and hospitals that serve them and the manufacturers of health products, lest the pace of technical innovation be impaired.

And so on, and so forth. Any health policy analyst over the age of 40 could easily double the list. It might make for a good parlor game at a bar.

Readers may believe I am jesting. But follow the editorial pages or punditry, especially of the conservative news media, over some time.

Health Reform Without a Public Plan: The German Model – Economix Blog – NYTimes.com

Health Reform Without a Public Plan: The German Model – Economix Blog – NYTimes.com:

“What if that [public option] plan were sacrificed on the altar of bipartisanship? Would it be the end of meaningful health reform?

“Not necessarily, if the health systems of the Netherlands, Germany and Switzerland are any guide.

“None of these countries uses a government-run, Medicare-like health insurance plan. They all rely on purely private, nonprofit or for-profit insurers that are goaded by tight regulation to work toward socially desired ends. And they do so at average per-capita health-care costs far below those of the United States — costs in Germany and the Netherlands are less than half of those here.”

When I get in discussions of HC reform with my friends who are more committed to a single payer solution than I, I point out that most countries we look to as exemplars of excellent universal health care do not, in fact, use the single payer model, but use some hybridized form of the Bismarckian, or Social Health Insurance model, such as Germany. This may explain why the American College of Physicians made its policy recommendations in 2007: though single payer was recommended first, a hybrid system was neck and neck and felt to be more achievable.

Dr. Reinhardt explains the overview beautifully here, and I cannot improve upon it. He, as always, provides great framing to his points that can be appropriated for the discussions you have on the topic. For more details on the German system, go here.

McKinsey: What Matters: Way too much for way too little

McKinsey: What Matters: Way too much for way too little

The title says it all. A great review of the American health care non-system.

Goes over administrative waste (83 cents of premium dollars go to actual health care at most in PHI market), outcomes, costs and prices, administrative burden, practice variation, and rationing (QALY’s CER).

Some good response letters as well.

What Is ‘Socialized Medicine’?: A Taxonomy of Health Care Systems – Economix Blog – NYTimes.com

What Is ‘Socialized Medicine’?: A Taxonomy of Health Care Systems – Economix Blog – NYTimes.com:

“Socialized medicine refers to health system in which the government owns and operates both the financing of health care and its delivery. Cell A in the chart represents socialized medicine.

“Social health insurance, on the other hand, refers to systems in which individuals transfer their financial risk of medical bills to a risk pool to which, as individuals, they contribute taxes or premiums based primarily on ability to pay, rather than on how healthy or sick they are.”
………..
“Former Mayor Rudolph Giuliani of New York has exemplified the perennial confusion in this country over socialized medicine. In his ill-fated presidential bid, and subsequently as a supporter of Senator John McCain’s bid for the presidency, Mr. Giuliani routinely decried as socialized medicine (or “socialist”) any proposal presented by Democratic candidates, because typically the latter advocated tax-financed subsidies toward the purchase of health private insurance or expansions of public insurance programs. But technically none of them advocated socialized medicine.

“Perhaps Mr. Giuliani was unaware that Americans all along the ideological spectrum reserve the purest form of socialized medicine — the V.A. health system — for the nation’s veterans. I find this cognitive dissonance amusing. Indeed, if socialized medicine is so evil, why didn’t Republicans privatize the V.A. health system when they controlled both the White House and the Congress during 2001-06?

“Mr. Giuliani also seems to forget that, in 1996, he found social health insurance a perfect solution to the financial problems faced by former Mayor John V. Lindsay, who fell on financially hard times during the 1990s as a result of chronic illness. “

The chart in the piece is a little tough, the text is better, specifically the first two paragraphs above.

But to me, the key is do we want to continue to decide who can get health care and health insurance based upon their luck? And I don’t mean luck in being financially successful, I mean luck in not getting a chronic, life threatening, debilitating illness. And if we get lucky, and make it to Medicare without a big illness, do we really want to rely on that luck holding out for our children, our nieces and nephews, our grandchildren? I don’t.

Uwe Reinhardt: A Medicare-Like Plan for the Non-Elderly – Economix Blog – NYTimes.com

A Medicare-Like Plan for the Non-Elderly – Economix Blog – NYTimes.com:

“A public health plan, however, strikes fear in the hearts of many interest groups. There are several reasons for this.

“First, it is only human that the politically powerful private health-insurance industry opposes competition from such a plan. The industry argues, not without justification, that a public plan might be advantaged by dictating to providers lower prices for health care services and products, and it might benefit from hidden subsidies. That unfair advantage could squish the private plans to the wall.

“But even if those comparative advantages could be eliminated through careful design of the public plan, the industry probably fears the inherent appeal that a public plan might have among the American people.

“The providers of health care and health care products, to whom “national health care spending” represents “national health care incomes,” fear the market power that a public health plan might bring to the demand (payment) side of the health sector.

“Greater market moxie on the demand side, they fear, might significantly bend down the lush, currently projected, long-run growth path of America’s health spending, which has national health spending rise from the current 16.6 percent of gross domestic product to 20.3 percent by 2018 and to 38 percent of G.D.P. by 2050. Once again, it is only human that the supply side of the United States health system prefers a continuance of the weaker, more fragmented demand (payment) side that for four decades now has allowed health spending to grow in excess of 2 percentage points faster than the rest of the G.D.P.

“The most powerful ordnance lobbed at the public health plan by its opponents is the dreaded “R” word, that is, the prediction that it will lead to the rationing of health care in America. In the debate on health policy, getting slapped with the R-word has always has been the kiss of death for any proposal.

“Evidently, many Americans do sincerely believe that when a public health plan refuses to pay for a procedure it is “rationing,” while denial of health care to an uninsured, low-income individual who cannot afford to pay for that care is not. But as textbooks in economics explicitly teach, the role of prices in a market economy is precisely to ration scarce resources among unlimited demands.

“The American health system has rationed health care by price and ability to pay all along for a sizeable segment of the United States population. In its report “ Hidden Cost, Value Lost,” for example, a distinguished panel of experts convened by the Institute of Medicine of the National Academy of Sciences estimated that some 18,000 Americans die prematurely for want of health insurance and timely medical care. That is rationing life years.”

National Journal Online — Health Care Experts — Paying (Or Not) For Reform

National Journal Online — Health Care Experts — Paying (Or Not) For Reform – Uwe Reinhardt Response:

It didn’t take long before one of several howitzers got dug in to shoot at the idea of universal health insurance. The one out now is the familiar ‘we need to control health care costs in our bloated, inefficient health system first before we can bring yet other Americans under the umbrella of health insurance and into the system.’ That cannon has served us well for over three decades now. I can imagine its roar already, even before the cannon is fully cocked.

To shoot this cannon, you must have a license, and the requirement for that license is that you must be well insured and, indeed, be one of the folks who have helped bloat the system and made in inefficient. And because we, the well insured bloaters, have come to love that system so, we’ll do everything in our power not to change the status quo, won’t we?

The other cannon, still being readied, is the ‘crowd out’ or ‘crowd in’ cannon. It gets deployed whenever someone in Congress or in the White House identifies the year’s ‘objects of compassion’ (OCs). For example, the OC’s may be uninsured children, or unemployed adults over 50, or whatever. The compassionate originator of the idea to do something for the OCs may calculate that it will take, say, $2,700 per OC to practice compassion upon them. No sooner uttered than the computers at the AEI or NBER or RAND or wherever start to whirr, figuring out how many OC-look-alikes now privately insured will be crowded into the new public program intended mainly for the original OCs. And before you know it, the federal budget cost calculated as (federal cost per original OC plus federal cost per crowded in OC) divided per original OC is staggering. Bullet hits on the mark, OC plan is destroyed. Mission accomplished.

This is how America has always successfully warded off any impending threat of universal coverage. Maybe it’ll work again this time.

There’s more…

Wanted: A Clearly Articulated Social Ethic for American Health Care

Classic Uwe Reinhardt piece: “Wanted: A Clearly Articulated Social Ethic for American Health Care.”

From JAMA. 1997;278:1446-1447

Throughout the past 3 decades, Americans have been locked in a tenacious ideological debate whose essence can be distilled into the following pointed question: As a matter of national policy, and to the extent that a nation’s health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?

The ‘yeas’ in all other industrialized nations had won that debate hands down decades ago, and these nations have worked hard to put in place health insurance and health care systems to match that predominant sentiment. In the United States, on the other hand, the ‘nays’ so far have carried the day. As a matter of conscious national policy, the United States always has and still does openly countenance the practice of rationing health care for millions of American children by their parents’ ability to procure health insurance for the family or, if the family is uninsured, by their parents’ willingness and ability to pay for health care out of their own pocket or, if the family is unable to pay, by the parents’ willingness and ability to procure charity care in their role as health care beggars.

I think this is a great piece and I can’t add anything to it and it is well worth the read. The responses in the letters section that followed are, sadly, very revealing about the debate then and now.

National Journal Online — Health Care Experts — The Public Plan: Time Bomb?

National Journal Online — Health Care Experts — The Public Plan: Time Bomb?:

“Can Congress fashion a public health plan option so that it does not blow up health care reform this year?”

I didn’t get invited to leave a response, so here’s mine:

Interesting discussion.

Dr. Nichols wonders if we have examples of regulated private insurers brhaving properly. At the risk of venturing beyond our shores, don’t we have examples in Switzerland, Germany and other Social Health Insurance Model countries? His examples of public plans already alive and well in the US seem like good models to consider.

Ms. Turner and Mr. Goodman seem to be arguing opposite sides of magical market place coin: One laments that privte insurers will never be able to compete with the public option, and the other that the private insurers will eat the public plans’ lunch. It is possible for them to co-exist, again, if one is willing to suspend the idea of American Exceptionalism and benefit from the experiences of other nations. I will venture to say that if Mr. Goodman is correct and the private insurers provide efficiency, quality and win-out, then “Hallelujah!”, and all of us skeptics of the efficiency and value of private insurers will have been proved wrong, will eat crow, and happily allow the private insurers to be our vehicles for value.

I don’t think this will happen, and it seems that Mr. Goodman may be conflating the role of private insurers in their function as Medicare Carriers and ther role as profit making (even when ostensibly “not for profit”) insurers, dominating their regional markets, and squeezing their policy holders and providers alike.

Dr. Reinhardt, of course, always nails things and does again here. I think he may have overlooked another latent demand among physicians and other providers. Depending upon where you practice medicine, Medicare may be your most reliable, hassle free and even, in some markets, your best payer. Private insurers, while paying significantly more in some regions, may cost providers more in time, hassle, staffing costs and the like that their reimbursement warrants.

Ms. Davis also frames the debate well by focusing in on the acknowledged truth that we must pay smarter, not just more and more and more.

Cheers,

Art Caplan Lecture – Society of Critical Care Medicine

SCCM – Society of Critical Care Medicine:
“Max Weil Honorary Lecture
Arthur Caplan, MD
University of Pennsylvania
Philadelphia, Pennsylvania, USA
Beyond Band-Aids: How to Cure America’s Ailing Healthcare System
Arthur Caplan, MD, argued that the United States healthcare system is broken, and it is important to evaluate the various healthcare reform proposals and their political feasibility. Healthcare professionals should have a prominent place in the discussion to ensure ethical and meaningful reforms.”

Dr. Caplan spent the bulk of his time making the ethical case for healthcare reform. He based his argument on the right to opportunity, or equal opportunity, of all citizens to be free from the encumbrances of illnesses untreated due to lack of personal resources or lack of resources from our social safety net.

Fair enough, but I think this argument will fall flat, of course, to those who oppose health care reform of any stripe, but I think it rings peculiarly hollow to most others as well, including the most fevered advocates for reform.

I will be flagging my ignorance of formal ethics and bioethics here, as I am, like most, simply an amateur (but nonetheless opinionated) ethicist. (But, I am an intensivist, so maybe I am semi-pro?)
I think in addressing health care professionals, it is reasonable to appeal to their professionalism. In the Charter on Medical Professionalism, we are called to advocate for Social Justice:

“Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. “

And this argument does need to be made to specialty physician organizations. Repeatedly. Many of our organizations have devolved into glorified trade organizations, only springing into action when income or clinical territory are threatened. We need to call ourselves and our colleagues to the better angels of our nature.

But this is really only the tip of the iceberg required to make the ethical case for universal healthcare. The real case rests on our common humanity, our common respect for the dignity of man, The Golden Rule.

A recent program aired on Bill Moyers Journal called “Beyond Our Differences”, which explored the common themes of all world religions. It is a terrific program and I advise everyone to watch it, preferably with your family.

Is there a moral philosophy on the planet that does not require us to care for the least among us? Is there one which does not require us to care for the poor, the sick, the hungry to the best of our ability? Is there one that does not require us to respect the dignity of our fellow humans?

I like to joke that there is such a philosophy, Ayn Rand’s Objectivism. Maybe there are other philisophical schools of thought that also reject these tenets, I will let the real philosophers out there correct me. But all religions, east and west, and secular humanism all carry forward this strong ethical mandate. As I look through my “Social Justice” subject tag, quite a lot are covered: Catholics and the Jesuits, Charles Dickens (and Protestants and humanists), physicians, Jews, and even the self-intersted. The “Beyond Our Differences” program covers these and more.

So, how to make the ethical argument? I think we must rely on our common humanity, our common philosphy of honoring the dignity of our fellow humans and doing our duty as citizens of a great country to “promote the general Welfare”.

But better yet, let me sum it up as Uwe Reinhardt would, “Go explain to your God why you cannot do this, and he will laugh at you.”