Monday, August 24, 2009
Must-read health care reform article
Whether left or right, if you read one article on health care reform it ought to be this one. It is so reasonable and such a departure from the received wisdom among the progressivetariat that I am surprised The Atlantic published it. Print it off and read it over lunch, and then go to a town hall meeting with a few sharp questions.
The article is spot on. There's fundamental structural problems in our healthcare system. There's nothing in Obama's plans to address any of this. He'd actually make some basic problems worse -- like the fact that we have a looming shortage of doctors coming. My sister went from OB nurse to midwife, but gave up and went into admin. She was too easy a litigation target. We need more practical answers like "quasi-doctor" midwives.
My only experience with healthcare is a failed foray with a small healthcare informatics company that specialized in dialysis. It may still be the only medical health record company with a proven record of cutting costs significantly, mostly by improving patient outcomes, thus reducing catastrophic costs. The founder's vision is that patient variability matters hugely when treating any chronic illness; that cook book medicine is suboptimal when dealing with difficult chronic illness ... which gives you worse outcomes and higher costs.
We thought we could expand the company's small-time success, but couldn't make it work. The system only cares about billing, not outcomes. Doctors are surprisingly un-scientific, and don't welcome change -- it's a medieval guild.
Chronic illness is where most of the money goes -- patients don't get better, they need to be managed over time. Their data is meaningless when measured against the mean -- you need to assess their data comprehensively against their own personal history to get insight. There's a great opportunity to do disease management against a handful of diseases. Diabetes would be my # 1 pick. Increased costs from diabetes alone will break the bank. McCain even mentioned "disease management" during the campaign, but was dutifully ignored by MSM.
So much for "hope and change."
Chronic debt will kill more of us than health issues, if Nouriel Roubini is anywhere near correct. Can you imagine what new taxes and government spending will do to exacerbate our present difficulties? He can, and it isn't pretty.
Our fiscal distress will end this discussion, and force us to reexamine lots of other federal spending. Albert Gallatin for Secretary of the Treasury!
By the way, the current national "Health Care" discussion is not about health care methods and practices, whether of delivery or management, and really never was.
Oh sure, tangentially some issues have been raised, like unnecessary tests and defensive medicine, but the basic challenge to the structure of delivery raised in this article and not been done.
Our current national discussion is all about obscuring past Democrat fiscal mistakes in their construction of Medicare in a haze of ever greater spending, as well as being about building a new, massive patronage machine. That is the limit of what we're discussing.
This wonderful article is much too substantive for a national political discussion, and better suited to a Hospital boardroom or a medical school faculty meeting; someplace where actual improvement can be expected to result. Maybe.
By SR, at Mon Aug 24, 09:39:00 AM:
I haven't finished the article yet, however a quick Google yielded results indicating that hospital acquired infection is roughly twice as high in the UK (9% vs 5%) as in the US. We wash our hands a lot, and go through millions of latex gloves, but there probably is an irreducible minimum number of hospital acquired infections.
Another "must-read" article, this time from the WSJ, on the various ObamaCare efforts, specifically targeting the transparent silliness of the sales effort, "So the health-care status quo needs top-to-bottom reform, except for the parts that "you" happen to like."
HIs take on the role of hospitals is pretty much on target. In most medium and big cities hospitals are about the only large employer left in the city (perhaps a bank or too), so there is huge political influence. You can go to smaller cities in rural areas as well where most other business are in older buildings in poor repair and the hospital is new, opulent and advertising on billboards on the interstate.
Suburbanites must drive to the city hospital rather than to a satellite or smaller emergency room because the city labor and graft requirements must be met.
Printing it, reading it, will comment later.
Thanks for this link. An excellent article. As someone who thinks that health insurance in its current form distorts the market, I loved his observation, in the context of what gets covered under health insurance, that you wouldn't expect your auto insurance to pay for your gas.
Infections acquired in hospitals greatly contributed to the death of both my parents.
By Christopher Chambers, at Mon Aug 24, 02:51:00 PM:
But..."I want MY America back!"
By Christopher Chambers, at Mon Aug 24, 03:32:00 PM:
[unslinging my AR-15 as I stand up next to Randall Terry] "I STILL want MY America back!"
This is an emotional issue and we all should support covering individuals through private health insurance. To conquer these serious changes, doesn’t it seem right to advocate for greater transparency in both quality and price information, for it overlaps with many other issues? http://www.friendsoftheuschamber.com/issues/index.cfm?ID=300
"Infections acquired in hospitals greatly contributed to the death of both my parents."
This is sad. Sadder too that it occurred subsequent to your birth.
Chris ... I assume you noticed that the guy with the AR15, spare mag in the back pocket, and sidearm was generally brown in skin tone, and he seemed black to the casual observer. The 'racist' with the gun, that the MSM whined about.
I think this article really hammers home the idea that there are many elements that are broken, and the 'fix' proposed by this administration will not be a fix at all. Having spent pleny of time in hospitals, and enough nights to form an opinion, I am not surprised that they're germfests. So is your bathroom and toilet. So how can a hospital really be clean when people regularly use bed pans, puke, bleed, sneeze, and generally arrive sick spreading around whatever it is that they have? And it's virtually impossible to sleep when you're a pin cushion, and whose temperature is taken on regular intervals along with the Bp, etc.
The system needs help, but it starts with each of us taking better care of ourselves. Hell, I'd love the opportunity to have loaded up an HSA over the course of the last 30 years, and a list of what it COSTS per procedure, no matter who asks. Instead, the price is jacked up to cover the uninsured.
By K. Pablo, at Mon Aug 24, 06:50:00 PM:
The JCAHO about two years ago placed great emphasis on hand-washing awareness efforts in hospitals, and I served on something called the "Hand Hygiene Committee" at the hospital at which I am chief of a department. We succeeded in getting significant improvements in hand hygiene among doctors and nurses (low 90's%) but could not for some reason crack the Respiratory Therapists' heads and their rates guttered about in the low 70%. These are the people handling the ventilators in the ICU's!
The simple act of obscuring straightforward, interpersonal economic transactions with regulation and governmental interference is a shame. Who is the government to say what I should and should not be able to spend my money on, to satisfy the whims of others? I demand the personal liberty to live my life as I choose, unbeholden to the open moralizing of others. If they want to live their lives a certain way according to what they deem "just," great; they should go do that and leave me alone.
And this is why prostitution should be legal; because the free market always handles moral goods approriately.
By Papa Ray, at Mon Aug 24, 10:22:00 PM:
Well, infection didn't kill my parents, doctors did. My Mother was killed by a blood clot from a simple operation. "someone" Forgot to give medication to prevent that. A common procedure which was omitted.
My Dad died from a reaction from a drug given to him after he was admitted for a stroke. No one called me or tested him before giving him a drug that is known to cause severe reactions in patients.
But all of that aside, if I can ever, ever do that, is the question of Health Care in general in the U.S.
U.S. Hospitals fall in three groups, the large university hospitals with money running out of their hallways and the best doctors wanting to go there to the County hospitals in rural or small towns that have good doctors and somewhat adquate facilites but are now overrun with patients because of the illegal population.
The third is hospitals in cities. These in my opinion are the worse, but not for the reasons you would expect. They have good doctors, nurses and adequate medical facilities but lack good administration from patient records, lab results and the hundred other things that hospitals must keep on top of in order to take care of patients.
More money doesn't seem to help and the new paperless patient bedside chart software is not only a joke but dangerous to patient morbidity.
The one I'm most familiar with lately is the VA faciliteis. Undermanned by doctors, nurses from other countries that seem to be proficient but overwhelmed and without good communication skills. Infection at these institutions is a problem also. All labor of course contracted with your taxpayer money.
These are problems that can't be corrected by massive government programs or policy. These are problems that must be corrected by the institutions themselves with assistance and more trained professionals and better oversight.
But not by the Federal Government.
I agree almost completely with the article. Especially the suggestion of having universal catastrophic coverage with a deductible starting at $50k. I also suspect, though, that efficient individual market behaviors could be achieved through the use of 30% or higher copays. I also think more inspiration could be drawn from successful national health systems of foreign countries.
By SR, at Tue Aug 25, 12:44:00 AM:
By Unknown, at Tue Aug 25, 07:53:00 AM:
Man, that is some spamming program Kumar uses- I get the verification word wrong about one third of the time but their program seems to have no problem with it. I do wish, though, that they would go elsewhere with their spiffy program and infect other sites!
Frontline has a superb interview with Naoki Ikegami about Japan's system, as well as T.R. Reid's report on the systems in Germany, Japan, Switzerland, Taiwan, and Britain.
By Seamus MagRaith, at Tue Aug 25, 03:08:00 PM:
Thanks for recommending this, as I subscribe, but skipped thit article because I judged by its title that it would be a whiny liberal rant against an imperfect world.
Why shouldn't we pay out of pocket, just like every other economic transaction? Cash on the barrel head at the end of the appointment.
What goods or services can the government provide well? And yet there are people who are serious to accept the socialism of the government to be the payer for all health services.
James, always nice to see that you can look at the other side with an open mind. Article isn't whiny but the rants by Hannity, Beck and O'Reilly are whiny and obnoxious. I challenged my husband (A Hannity fan I might add) to pick out 1 time in the whole hour that Sean actually said something that was CONSTRUCTIVE. Couldn't do it. All he did was whine and rant and say, "I want my country back!!!" The country he wants back is the 1950's, before Brown V Board and women's rights. He wants it to be a gun toting, cousin loving, rural mishmash where the educated are gods and the "little folk" are the women, minorities and the poor. Talk about elitist.
If he wants his America back, he and all of you should put forth SOLUTIONS, not babble. Questioning someone's citizenship and making everyone scared is not the way. Fear and intimidation only works for a while. And those tactics are used as much, if not more by the right than the left. Do you all not remember "the moral majority". Thank god they're gone. OH no, Ralph Reed is coming out of the dung heap. Save me from that type of morality. I am not a big Obama fan but I'll take him any day over the Ralph Reed, Bill Bennett, Dick Morris's of the world. And you should too.
By Kinuachdrach, at Tue Aug 25, 08:57:00 PM:
From the article: "my father was killed by a hospital-borne infection in the intensive-care unit of a well-regarded nonprofit hospital in New York City.
...Dad had just turned 83 ..."
It is hard to comment on that without seeming cold & heartless. But I don't expect to live for ever. Nor should you. And I really doubt that your dad did either.
Everyone dies of something eventually. Every single one of us. Let's be glad when someone far outlasts the Biblical three score & ten, with his full faculties up to the end.
The ones I feel sorry for are those kept alive through a decade of dementia, incontinence, and indignity. Your father was much, much luckier than mine.
By SR, at Tue Aug 25, 10:56:00 PM:
Damn vicky, but you are an angry one.
By Dawnfire82, at Wed Aug 26, 10:16:00 AM:
"I am not a big Obama fan but I'll take him any day over the Ralph Reed, Bill Bennett, Dick Morris's of the world."
This is not a rational contrast. Obama is the President and leader of one of the major parties of the country, someone who is actively involved in making policy and possesses vast political power. (not influence... power) Those other guys are private citizens involved in politics whose philosophies you don't like. (Bennett hasn't held an office since the Bush Sr. Administration, Reed never held office, and Dick Morris worked for Bill Clinton)
I could just as easily state, 'I'm not a big McCain fan, but I'll take him any day over the Markos Moulitsas, Janeane Garofalos, and George Soros's of the world.' That those other three exist does not justify my nominal support of McCain; it just makes me feel morally superior to say so. At best, I could oppose a politician because he favors policy also favored by Soros, but not simply because Soros exists and calls himself a liberal. That's not a reason, it's an excuse.
You would probably be offended if I painted you with the same brush I would apply to people like, say, William Ayers, (self-confessed anti-American terrorist) Michael Moore, (fat, deceitful propagandist) and Keith Olbermann (frothing pseudo-intellectual ideologue who abuses his position on TV to insult and harass people he doesn't like). And you ought to be, because you are not them. You haven't done those things (I assume, here) and you don't deserve the kind of contempt I heap upon them.
Labeling an entire group of people according to the words or behavior of its fringe is wrong. At least, it's wrong when Republicans do it. Then it's 'profiling' and 'bias' and 'prejudice.' 'Without nuance' is another favored phrase.
Is this another double standard? It's ok if it is... I'm used to them by now. I had the fun experience this summer of being explicitly told (afterwards) that I was denied a position with a certain well-known agency for which I was fully qualified (the recruiting officer even referred to me as a 'shoo-in') because I was a white male and they had to make room for the women and minorities and even though I had an exceptionally good resume, it wasn't good enough to justify taking their reserved spaces.
Wandered a little off-topic there...
That's not anger, babe, that's frustration.
Dawn, double standard? If that company is doing that in this day and age, they are just using it as an excuse. You don't want to work for them anyways. Though, there are times when I get tired of the "I'm a white man so pity me" excuses. Maybe it is because I came of age in the 70's where, when I applied to graduate school in 1973, the head of the department said to me that no matter how good I was, he was not going to accept a woman in to his department. I came of age in an era where, as a young woman, I was discriminated against and hired only as an oddity, a woman in marketing. Hopefully we have gotten away from that. My daughter, now in her early 20's has had none of that discrimination but is still treated as an oddity because she is half mexican american (college educated and finishing up her last year of law school). Let's all get beyond this, hiring the right person for the job. Neither side can seem to move from this position. The lefties seem to think we need preferential treatment and the righties thinking they have been wronged because the white males are not getting preferential treatment. A conundrum to be sure.
I can understand your frustration, but, get over it.
WE all, and I am guilty of it too, place people in boxes and like to label people. It is our fatal flaw. I have been reading the right wing blogs about the death of Ted Kennedy and have read nothing but vitriol and hatred about some of his accomplishments as a senator. For sure he was an uber liberal, and that does rub some people the wrong way, but he was able to, in many cases, reach across the aisle and help affect change. You all love"No child left Behind" and the Medicare prescription drug program, both pushed through by Bush. Without Kennedy they would have never passed, never. So... he was not a commie, a socialist,or the devil. A man, pure and simple, good, bad mixed together.
I'm off subject too. I was afraid that if I posted this with the obit I would get slammed. May get slammed here too. OH well.
Four Supreme Court justices recently treated white New Haven firefighters as invisible men -- buying the NAACP's argument hook and line. Most colleges now have more women than men. Every major law firm has a diversity program that would affirmatively favor your daughter over my son, if he ever went to law school. Lower level schools are failing our boys, but no one cares.
Yet you're the whiner here.
Good article. I am also amazed that it was printed. My father, the doctor, would have approved.
Vicki said, "...and the righties thinking they have been wronged because the white males are not getting preferential treatment."
When I lost a promotion to a woman with a fraction of my experience because "there were enough men already at that pay grade" I did not want preferential treatment.
Vicki, don't misrepresent what the other side thinks and says. Can you cite any sources of mainstream conservative leaders who advocate preferential treatment for white males?
Tyree, they whine and complain about how HARD life is for the white male. They don't have to advocate it, they live it. Example, Glenn Beck spends part of every program bemoaning the fact that white males are being discriminated against. Sean Hannity whines, I want my country back!!!" Please, Whiners all. These are not elected officials to be sure, they would not say anything so "racist". So they call others "racist" instead.
Move on, go forward. That's what we all did in the 70's. Life isn't fair, as my husband says to our daughter, you just put one foot ahead of another and go on.
So Vicki, how much does Axelrod pay you an hour to camp out here and be annoying?
By Dawnfire82, at Wed Aug 26, 06:56:00 PM:
"If that company is doing that in this day and age, they are just using it as an excuse."
Government agency, not private. Federal. That is, it has once again become the policy of the government to discriminate based on race and gender. You know, the kind of behavior that the (Amended) 1964 Civil Rights Act was supposed to address.
"I can understand your frustration, but, get over it."
You JUST brought up a case of gender discrimination that happened to you more than a generation ago. An entire social and legal movement arose to end the practice and reverse the trend.
I brought up a case of race/gender discrimination that happened three months ago. I just have to "get over it."
Why? Should I just learn and get into my place and stay there? Should I have to work extra hard and be conspicuously more successful to get a position on account of my genetic characteristics?
What would your reaction have been if, in 1973, I heard of your incident and told you to simply get over it?
I think that "fuck you, this is unfair" would have been a natural response.
"You all love"No child left Behind" and the Medicare prescription drug program, both pushed through by Bush."
Who are you to tell me (or anyone here) what 'we' love? For instance, if you actually paid as much attention to conservative politics as much as you want us to think that you do you'd know that Bush was thrashed mercilessly by many conservatives for the Medicare program as yet another unsustainable entitlement thrown as a sop to the AARP, a special interest sellout of the core conservative principle of fiscal responsibility, in order to help solidify political support among the elderly.
"Tyree, they whine and complain about how HARD life is for the white male... Glenn Beck...Sean Hannity..."
'Don't discriminate against me' is not the same thing as 'treat me better than everyone else' and to suggest otherwise is blatantly dishonest.
And 'don't discriminate against me' is not whining, and to suggest otherwise is morally reprehensible. That labels all sorts of equality activists from Frederick Douglas to Shadi Sadr as spoiled children who should have shutup and been grateful for what privileges they did actually enjoy.
Or is it only whining when white males do it? I daresay that this is the correct answer.
"Life isn't fair, as my husband says to our daughter, you just put one foot ahead of another and go on."
Life isn't fair, but the law is supposed to be. Maybe your daughter could tell you about that.
BTW, you didn't actually supply the example requested by Tyree. I read that to mean that you cannot find any mainstream conservative leader who advocates preferential treatment for white males, and that you surrender the point.
And for the love of god, get off the 'Glen Beck/Sean Hannity say X' crap. They are not prophets of conservatism. I do not, and have not ever given a rat's ass about anything either of those two men have ever said. They are not political figures, either as leaders (as Tyree specified in his challenge) or as theorists. They are talking heads who pander to certain generalized viewpoints and demographics. That's all. It's political theater/show business that has only occasional real political usefulness in broadcasting some issue.
From Link to Vicki.
I for one am not bitter. I'm pissed off and angry when I think about politics, which I didn't used to do very much. I'm not Sean Hannity, either. Sean Hannity isn't even the Sean Hannity you portray. "I want my country back" isn't the same thing as "women should be barefoot, pregnant and in the kitchen" as you make it out to be. I second everything Dawnfire just said -- and he and I don't always agree. You're becoming another CC.
A question to the group: Does anyone know if research has been done to connect the dots of personnel relationships between DC lobbyists and our elected representatives, including by blood and marriage? For example, Joe Biden's son is a lobbyist. I understand that some lobbyists or high profile lawyers are married to elected representatives as well. An analogous connection is that Barney's Frank's former boy toy got a cushy job at Fannie Mae. This isn't just Democrats; Republicans play too.
I suspect that many top-end DC households have an insider who has the juice and an outsider who makes the money. The outsider relies on the aura of connection that comes from the insider. It's also a way to funnel bribes. Gov Blago had folks hire his wife as a real estate agent -- same idea, small potatoes by comparison. My thesis is that DC is one big cesspool of open corruption, all paid for by the rest of us. Note: if you give a Congressman money once around the time he does you a favor, it's a bribe; but if you give all the time it's only loyal support from a concerned private citizen.
By JPMcT, at Wed Aug 26, 09:49:00 PM:
Well, I read through the article and I must say that I am clearly NOT impressed with it.
There's nothing new about a program that pays for catastropic care. That's basically what republicans have been saying for years...and falling upon deaf ears.
I am also very leery about people who establish themselves as health care "experts" because they have seen something bad happen in a hospital.
A lot of what this author says happened to his father is WAAAYY off of the bell curve for hospitals. The mortality rate for an 83 year old man with penumonia is actually quite high. the fact that he became septic is not at all unusual...and it may have been a community acquired organism that he entered the hospital with. Doctor's "resisting the idea of hand washing" is an absolutely ridiculous statement. That work was done by Semmelweis over a hundred years ago...not by some latter day epidemiolgist. Most of us don gowns and gloves to enter the room of a patient on a ventilator, the mojority of hospitals have universal precautions for MRSA infections, every doctor I work with washes his hands a hundred times a day and all hospital rooms have germicide dispensers on the doorways.
What this author suggests is going on in American hospitals is laced with inaccuracy, hyperbole and, I suspect, fantasy.
The big gorilla in the room...the lack of sensible tort reform, did not even earn a singe sentence in the article.
Sorry, Tigerhawk, the article is garbage...and not very conincing garbage at that.
Jp we are talking sensible tort reform. For some people, screwed by the healthcare provider and the insurance company, this is the only way to get some type of restitution for malpractice and denial of service.
I guess the word sensible is key.
What does 'screwed by the healthcare provider' mean by way of concrete example? I've had 8 surgeries where I was put all the way under, and a number of others. Sometimes I felt the doctor's fee was unfair because there were charges for what I'd cal set-ups (I'm an accountant). I figured, once you're in there, does it cost the same to do 3 as 1? I've negotiated, not to zero, but to what I felt comfortable with. I like to pay 100% for service I feel merits it. I just did this on a recent procedure, where my Phd/MD surgeon made less than the anaesthesiologist who wasn't even in the room. And his annual take is that of a middle manager. I think the average income of a doctor would shock most people, particularly when they realize that the general practitioner isn't a modern Kennedy or Rockefeller. These people have an extra decade of training/education to make a fairly modest income.
Tort reform is needed because the effect of a few bad apples means that we all pay dearly to cover the overhead of the office, for tests that may not be needed (other than to forestall a downstream lawsuit), and for the insurance itself.
The trouble with the high deductible insurance for the younger folks is simple in my mind: insurers must make a TON on these people, who pay good money and use near zero insurance benefit dollars. They underwrite the older folks in the pool. And eventually, you get back to the problem with the government plan ... why be insured at all if you get it free from your Uncle? Get it on some else's dime. That's part of the America I'd like back. You pay your fair share.
The lack of actual tort reform will dog this effort, and the democrats who profit from their partnership with lawyers.
As for denial of service. I have a family member who just came out of the ICU. No insurance, next to a guy the hospitals had in the ICU for weeks. They don't know who he is ... he was picked up off the street and hasn't be conscious the entire time. There is nothing on the chart to indicate that either are uninsured, and their medical treatment is no different than any fully insured patient. The providers are on the payroll of the hospital. Healthcare people don't draw a line on who gets helped. But everyone has a story, and too often it's the choices the person made that (a) have them uninsured, and (b) in treatment. Witness the many dollars spent on the cigs that gave the heart attack, and not spent on insurance.
Now, walk into a doctor's private offices and get turned away? Sure, and I'd do the same thing. You'd get triaged if you coded, but they'd be calling 911 to come get you. It's not a free clinic, or government backed hospital, and the doctor shouldn't be expected to work for free any more than the plumber or electrician who comes to fix/repair a problem in your home.
By JPMcT, at Thu Aug 27, 07:05:00 AM:
"screwed by the healthcare provider and the insurance company"
Last time I checked, people signed contracts with health insurance companies...but, then, the whole idea of contractural obligation is out the window with "hope and change", heh, vickie. I'm sure if there were a "United Health Care Workers" union, and they contributed heavily to Democrats, they would be getting a huge slice of the "pie" that would be left over after the DC feeding frenzy.
The only people that reliably get compensated for most malpractice awards are the attorneys, who walk away with 30-50% of the lottery winnings.
The rest of us pay up front in higher healtcare fees because of the gazillion diagnostic studies that get ordered for "ass-coverage" because of the malignant liability atmosphere in clinical medicine.
I could go on for an hour with examples...but since I'm talking to the hand, there is no point.
Is a short article about a small domestic 147 year old ladder manufacturer that went out of business when the cost of liability insurance consumed almost 30% of their sales. Every hospital that bought buys a ladder has to pass that cost on to the consumer. Tort reform would help everyone, except the lawyers and their cronies in Nancy Pelosi's "Culture of Corruption".
As for Vicki and her ilk, you can't reason someone out of a position they were not reasoned into.