Tuesday, February 24, 2009

Health Care Reform -- Essential Reading

When I come across links as rich in content as these I get frustrated that traffic to this blog is so low. It's my own fault. I put up a disorganized collection of scrap-book -like keepsakes with few main themes. But the pursuit of health care debate information has led me to some unexpectedly top-quality thinking and reading. Here are three links that should be on every one's reading list, no matter what position they hold, if they intend to call themselves informed.

First, the Diamond-Orszag for Social Security reform, (9 page pdf) dated from four years ago. There is no way to know what it might look like after it goes through the Congressional sausage grinder, but as written it is as delicately balanced as a Swiss time piece. What has Social Security to do with health care? Easy. Beneficiaries of Medicare also qualify for Social Security benefits at the same time and Medicare is joined at the hip with Social Security. Medicare Parts B monthly premiums are charged to the beneficiary by a withdrawal from their Social Security check. Also, although no monthly premium is charged for Part A, the annual deductible increases as the costs of health care are passed on to Medicare. Even though a separate payroll tax is designated to fund Medicare, Social Security provides a critical revenue stream for that part of the population receiving benefits from Medicare, many of whom, as in the case of Social Security beneficiaries have no income to make contributions.

(A word about Social Security reform... No official, updated plan has been proposed yet, but scare-mongers are already screaming that "they" are trying to "gut Social Security" and "take away our benefits." This is a bunch of crap. To start with, anything along those lines would be politically suicidal and there are too many smart people in Washington to come close to anything like that. The Diamond-Orszag Plan linked above consists of three easy to understand parts. 1. Adjust the age of "full retirement" to reflect our increased life expectancy. Early access to the system at age 59 would not change. 2. Raise the income cap from which the tax is collected. This year that would mean nothing to anyone not earning under a hundred thousand dollars. 3. Using a means test based on individual private retirement arrangements, adjust Social Security benefits to reflect those other assets for those who have set them aside tax-sheltered during their working years. The plan specifically states that "individual accounts would create a massive cash-flow problem for Social Security." The Diamond-Orszag Plan does not aim to molest private plans in any way.)

As you read about health care, try to remember that nothing comes without a price. It's simple arithmetic. Just like your home budget, only much bigger, any benefit received must be paid for, typically (and fortunately) not by the one receiving the benefit. Remember, too, that the Medicare portion of the overall health care picture is but one piece of the much larger combined universe we tend to compartmentalize. Health care is not an assembly of unconnected compartments but a single big economic animal depending on a variety of revenue streams which include private insurance (both individual and group), co-payments from insured people, government money from Medicare and Medicaid, and charitable gifts funding a variety of capital and community needs by not-for-profit providers.

Second, read what Maggie Mahar says in The Truth about Medicare and Private Insurers, Parts I and II. The nub of her point is that the demon we are fighting is not altogether exploitation of the system by private insurers to collect enough extra income over and above costs to furnish profits to shareholders and handsome bonuses to top performers and executives. The real problem, she points out, supporting her point with facts, is health care inflation. The actual cost of health care in America is increasing annually at a rate exceeding both inflation and GDP. Records going back thirty-five years tracking annual increases separately for both Medicare and private insurers show double digit annual percentage increases until 1990 and very little improvement since. !n 1998 private insurers got costs down to 4% over the preceding years, and in 1994 Medicare had costs down to 3% but with those two exceptions the picture has not been good. "From 2000 to 2006, the amount that [Medicare] paid for healthcare grew by 6 percent to 9 percent each and every year. This is why Medicare premiums, deductibles and co-pays have been rising." There is no way to summarize the range of links at Maggie Mahar's blog or simplify the topics they cover. The reader can spend a very long time drilling into the many resources cited and looking (for a change) at comment threads from informed professionals who know how to disagree in a (mostly) civil manner.

Third, Dr. Robert Wachter at The Health Care Blog asks Are We Mature Enough to Make Use of Comparative Effectiveness Research? This is one touchy issue. The stimulus bill that just passed included large amounts of money to look into the matter of effectiveness of drugs and treatment options. According to the sidebar, the post that has stirred the most arguments at The Health Care Blog is about that subject, Fear and Loathing over the Stimulus Bill. It illustrates how heated the debate will be once it gets up to speed. For a variety of reasons the notion of comparing outcomes and efficiencies is a scary idea. So long have we been told that "government health care" and "socialized medicine" are the hidden agenda of the Obama administration and a host of sinister forces seeking to kill off old people and babies, ration scarce resources, and push for more physician-assisted suicide that it's hard to breath in the polluted air surrounding informed discussion. Here is a snip from Dr. Wachter's post...

Here’s where things get dicey. A chief medical officer I know was once discussing unnecessary procedures in his health care system. In a rare moment of unvarnished truth telling, one of his procedural specialists told him, “I make my living off unnecessary procedures.” Even if we stick to the correct side of the ethical fault line, doctors and companies inevitably believe in their technologies and products, making it tricky to get them to willingly lay down their arms. Robert Pear described the political challenges surrounding effectiveness research in last week’s New York Times:

[the legislation has become] a lightening rod for pharmaceutical and medical-device lobbyists, who fear the findings will be used by insurers or the government to deny coverage for more expensive procedures and, thus, to ration care. In addition, Republican lawmakers and conservative commentators complained that the legislation would allow the federal government to intrude in a person’s health care by enforcing clinical guidelines and treatment protocols.

At this moment, Medicare’s rules – yes, the same Medicare that’s slated to go broke in a decade or so – forbid it to consider cost in its coverage decisions. Rather, its mandate is to cover treatments that are “reasonable and necessary.” So if Medicare comes to believe that a new chemotherapy will offer patients an extra week of life at a cost of $100,000 per patient, it is pretty much obligated to cover it. This is insane, obviously, but such are the rules.

And, if anybody tries to put the Kybosh on the Chemo, you can count on boatloads of oncologists, patient advocates, and pharma companies to descend on Washington like teenagers with Obama inaugural tickets, hammering the authorities to “be humane” and “take the decisions out of the hands of government bureaucrats and MBAs” and “put them in the hands of doctors, where they belong.” (This is precisely what happened in at Medicare’s hearings regarding cardiac CT, a technology that Medicare decided to cover despite a striking dearth of evidence of effectiveness). And TV news magazines will be right there, telling the compelling and tragic story of the kindly grandma who will never see her grandchildren’s bar mitzvahs because of Medicare’s heartlessness.

As Stalin said, “a single death is a tragedy, a million deaths a statistic.” Such is the problem with trying to make rational, evidence-based tradeoffs (that lead some people to not get the care they want) in a media-saturated open society.

I remember a snide aside from another blog:

Question: Why do coffins have nails?
Answer: To keep the oncologists out.

This bitter observation gets to one of the most important reasons for what is delicately being called "health care inflation." Too many drugs and procedures that are not medically justified. It's simple to say but hard to get under control. We are a sales-oriented culture and our mission is to sell, sell, sell. That is as true of health care providers as it is for retailers. As that doctor said so plainly above, he makes his living off unnecessary procedures. It's no accident that the two most expensive and high-profile additions to a local hospital were capital outlays for a cancer center and a heart center. From my reading, those are the two most lucrative of all modern medical specialties. Never mind about whether or not those breathtakingly expensive cancer protocols lead to verifiable positive outcomes and that unneeded heart surgeries are proliferating like tonsillectomies did when I was in school.

These are hard pills to swallow. But I urge the reader to brace for a tough look at some realities we all want to ignore. In the last two weeks of study I have come across two items that stick in my memory. The first is a snip form a video I linked about Canadian Health care. A woman in a Canadian hospital was asked about advertising their services and she replied, somewhat surprised, that she worked in a hospital. There was no need to advertise because people know what they needed without it. Besides, too many people coming in would mess with her budget. The way she said it struck me wrong at the time, but the more I think about it the more it makes sense. Here was a professional who also had a grip on the expenses involved in what she was providing.

The other item I remember was that in Sweden all preventive health care measures are free, from pap smears and mammograms to diabetes screening and checks for other conditions. As a result people with chronic disease have no reason not to take advantage professional assistance caring for themselves. For my wife, who has a family history of breast cancer, this seemed like a dream.

My homework continues.
I'm just starting and these are a couple of my notes.
If even one reader finds them to be of value I would appreciate a comment to let me know this effort was not in vain.

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