Sunday, April 25, 2010

Blue Collar

Now that your finances are in order, I understand there's a problem with your plumbing.

Oh my. That sounds troublesome.

I'm really very concerned about this situation.

Let me give you my professional opinion.

Use diapers!

Diapers! Diapers! Diapers!

Diapers for everyone!

Cause the garbage man's gotta work too.

Thursday, April 22, 2010

Organized insanity

Got back from the Medical Society of the State of New York meeting over last weekend where many health system reform issues came into focus for me. I'd say the crux of the problem with the reform process is the closed-minded approach that many people have committed themselves to at this point. It's McCarthyism and hyperbole, all the way.

At one reception during the meeting a man overheard me say that I was glad that the reform legislation passed, despite that it left so much unaddressed and so much work still needs to be done. This comment, apparently, sealed my character in his mind and probably led to this subsequent exchange several minutes later...

Him: "Obama thinks doctors would rather charge thousands of dollars for a tonsillectomy than prescribe antibiotics. Senator Schumer thinks that doctors charge $4000 to a patient after they wave at them in the hall. Obama says we'd rather amputate a diabetic patient's foot than keep their sugars controlled..."

Me: "Well, there is a grain of truth behind the hyperbole because..."


Me: [trying to clarify, but unable to get a word in edge-wise] "No, none of those things are real, it was hyperbole... I only meant that there is truly an incentive for overtreatment in our system..." [etc]

I genuinely thought for a moment this man might go ballistic and start throwing punches. His wife, also a physician, looked at me as if I were slimy. It was not a pleasant conversation. Nor was it really... you know, a conversation.

Misunderstandings are unavoidable, I think, in a conversation about something as complicated as our healthcare system. However, ironing out misunderstandings requires more conversation, and the types of misunderstandings I've seen have been based on dogma and ill-will often enough that more conversation is extremely unlikely. People retreat to their respective tents to reinforce their existing biases and dialog goes nowhere.

Luckily for me, people who read this blog are generally my friends/family and are willing to give the benefit of the doubt. Conversations are possible here, if limited by the medium.

So, here are a few follow up thoughts from my last post.

The overarching goals of healthcare reform are (in my mind... and evolving all the time!):
  1. Making care of the highest quality
  2. Facilitating the economics of care
  3. Promoting freedom and associated responsibility
In order to make care of the highest quality, we need comparative effectiveness research in the best sense: information about the best ways of delivering care that is not solely dependent on industry funded research, and that does not interfere with the autonomy of physicians and patients.

Case in point from MSSNY: one of the resolutions asked for policy that supports mammography guidelines from the 2002 USPSTF rather than the more recent guidelines. Some believe that the government has removed the rights of physicians and patients to screen from ages 40-50, and that this decision was a kind of rationing of healthcare resources. In fact, I read the new USPSTF recommendations after the meeting and they emphatically stated that they were only recommending against "routine" screening in this age group and that access or payment should not be denied based on their recommendations. Essentially, they just wanted to the doctor and patient to actually talk about the risks and benefits before enacting a rote screening algorithm.

The new healthcare reform law includes provisions for publicly funded comparative effectiveness research. Opponents cite the inability of the government to administrate anything effectively ever, which is a bit lacking in nuance. I'm glad CER is included. I think it will prove to be money well spent, and public money is the only money that will fund some of the most necessary data as there is a financial dis-incentive for decreasing certain costs.

I mentioned in my last post that transparency of cost is something crucial for reform that is largely ignored in most conversations. Proponents of a public option (or, more inciting, a dreaded single-payer system!), point to the ineffectiveness and broken nature of our current "free market" system. We've tried it and it's not working, they suggest. I've never had an economics class in my life (lamentably), but if nobody knows what anything costs or makes any actual supply/demand decisions about consumption, I don't see how our current system is much of a free market. Regardless of the left or right leaning direction of proposed reforms, I see cost transparency as a necessary starting place for any real accountability by anyone.

There are incentives to over-treat. It's a fact. However, vilifying physicians as parasitic and unconscionable predators is not only politically stupid, it's unfair and contributes to the polarized unfriendly nature of the conversation.

Philosophically, freedom is a mixed bag. Grown-ups understand (hopefully) that obligations are attached to certain decisions and so freedom is never fully free. I bring this up because it's the principle that seems so often disguised and/or misunderstood whenever we consider healthcare reform.

People need to actually pay in some manner or another for what they receive.

It's the economics of the universe that entropy isn't going to carry you comfortably through retirement. Someone's gonna have to pay, and that someone is likely you earlier in life. Now, the manner in which this is arranged is a great debate. Should it be through health savings accounts or public programs? I have friends/family on both sides of that issue and I'm aware of merits and drawbacks either way. I've personally decided I favor an insurance mandate, and I'll explain why.

Requiring people to purchase health insurance is distasteful because it removes an individual's options of how they want to pay for their healthcare. It takes away freedom in the literal sense. It imposes an approach that means profits for insurance companies at the compulsory expense of working individuals and families. I appreciate this problem. However, I think this is mainly an academic issue as very few people are wealthy enough to self-insure. Extremely few. And those people who are wealthy enough typically buy insurance anyway. We're talking about a legitimate loss of freedom by a very very small group of people.

That's the harm of mandating insurance, so what's the benefit? In our society we don't just let people suffer. We care for them. And that care costs money. Frequently the people who need the most care are the people least able to pay. In our immediate past we have tolerated tens of millions of people disconnecting choice and responsibility through not having health insurance. Many good people believe they don't need insurance because they are healthy enough or wealthy enough that not having insurance is the better economic option. In the pools of shared risk, most of them are right, but there will statistically always be high costs for everyone to cover those who end up wrong. The inevitability of that displaced cost means the everyone's freedoms are limited by the choice to not carry insurance by this pool of people who seem arguably justified in doing so.

Take for example, this article.

Karen: "No one in my family has has ever had to go the emergency room. Our belief system is that if you know who you are, you won't even need ER visits."

Your belief system seems to ignore that bad things happen to good people. Would you shoo away the ambulance after a car accident and just hold pressure until you get in to see your FP?

Joan: "I just have strong opinions about taking care of yourself, and I'm willing to pay the consequences for that point of view. If I get sick, well, I guess they can just scrape me up off the street and put me in with the landfill!"

Lovely sentiment, but our society doesn't work that way. You can't have the economic benefits of American society if you want the social responsibility of Afghanistan. You get a matched pair.

I could write a response to each of the folks highlighted in the article, but you get the idea. Mandated insurance isn't a perfect solution to the problem of freeloaders, but it certainly brings the costs of healthcare risk to a larger portion of the healthcare risk consuming pool. In this way, it actually increases the freedom of the majority not to subsidize the care of others. People can be delusional about the way they are subject to healthcare risks (statistics make it very easy to fool yourself... just like smoking is overall unlikely to kill you and yet simultaneously is the leading cause of preventable death our country faces.) and consequently displace responsibility for their own poor decisions on society. Mandating otherwise is, unfortunately, both effective and necessary. On balance, the freedoms gained outweigh the freedoms lost.

Without going into the relative merits of a democracy versus a republic, I will just acknowledge that our leaders did act against public sentiment by passing the law they did. And, although violating the will of the people seems reprehensible, one may argue that on occasion leaders of a republic act in the best interests despite the will of the people. Because one's own understanding of the issues determines whether you see it as reprehensible or politically courageous to violate the will of the people, I don't really factor any of that in my views of the central issues of healthcare reform.

Sorry for the long post. I still didn't manage to say as much as I intended! But... well, there's that much.

Sunday, April 11, 2010

Healthcare Insurance System Reform

When a lot of people talk about the healthcare reform Congress just passed, it's some form of the question, "What exactly just happened?" There are a lot of details, but the two headliners are that insurance coverage can no longer be denied for pre-existing conditions, and everyone has to have health insurance.

For some, passing this bill is so distasteful as to somehow be associated with "Armageddon" (per minority leader Boehner). But when I step away from the hyperbole and fear-mongering (Glenn Beck, I'm looking at you), my short thoughts are: this is a good thing, it could have been a better thing, more is yet to be done. As to the title of the post, the reform that was passed was mainly a change in how we pay for healthcare rather than addressing the problems with the medical system itself, and I do believe it will have a positive net impact on us as a country. However, the most fundamental problem with how we finance health care has not been addressed, and that is that nobody--from the patient to the various team of healthcare providers--knows how much anything costs.

Maybe it's an extension of the obfuscated costs of healthcare, but discussions of healthcare as a "right" and the inevitability of "rationing" all stem from some absurd idea that the resources for healthcare follow a set of unique existential laws separate from all else we consume. Somehow many people seem to believe that nobody has a right to tell anyone when to pull the plug on Granny, but are hard pressed to explain who should pay for these expensive benefits Granny et al can't afford. The fact is, it's all expensive--very very expensive. And unlike everything else in my life that costs a lot of money, I'm prevented from doing cost research, taking advantages of sales and price breaks, or any of a zillion economic tricks that have kept my family living comfortably on a resident salary for years. But, it hardly matters when the bills are paid by the borg--some collective of University, government, insurance company, and hospital resources that combine to take care of things in a manner that recycles all the very real costs into a smattering of undetectable accounting tweaks that make me feel like I'm not really paying for it at all. It's an employment "benefit". Woop-dee-doo.

Anyway, all that is to say that in my view the real problem with the medical system is that people have not been allowed to understand the value of their care--how much it really costs. And until we are given that, other cost cutting measures are stop gaps that will only put bandaids on the severed arteries of our economy. This bill didn't address that fundamental aspect of cutting medical costs, and, somewhat understandably, that made a lot of people oppose it. I ignore the deficiencies in what the bill could have been in favor of appreciating what it did do.

As a nation, we've decided basic healthcare is a right. It's already done. That is to say, if someone shows up at the ER bleeding to death, we don't check their insurance status before saving their life. If they can't pay, we all pay for them. One can make the argument that this should change, but I don't see that as politically feasible, moral, or consistent with my own values. So, I accept as a given that everyone consumes healthcare in this country whether they pay for it directly or not. For healthy young people, the consumption is of the obviated risk of unfinanced catastrophic injury rather than direct medical care, but the consumed benefit is real just the same. Since everyone receives this benefit, it's only fair that everyone should be made to pay rather than freeload. And that's why I personally support mandated health insurance as an appropriate intrusion into our personal freedoms.

Detractors have many arguments against the reform, but the ones I hear most frequently are these:
- mandates are unconstitutional
- healthy individuals should not be made to pay for the benefits of the unhealthy
- those whose behaviors make their care more expensive should not be subsidized by their more personally responsible counterparts
- the government can't be trusted to do something this big correctly

I bit off more than I could chew by starting this post, because I realize to do it justice will take a lot longer than I have right now. But, add to my list of detractor arguments in the comments and I'll try to write more later. Thoughts?