The breakdown in health care reform talks is not only because Republicans plan to obstruct any and all Obama-favored legislation (although that obviously is most of it).
Bipartisan kumbaya, even on the most basic health care reform principles, has failed to materialize, in small part, because Democrats refuse to acknowledge a few burning problems with the pending Democratic bill proposals.
Yes, I realize I'm committing liberal blasphemy by publicly admitting that the House healthcare bill is imperfect. But the truth is the truth, no matter how hard or unpalatable. And the truth is that a few elements are intrusive and/or wrong, and a bit creepy.
One such element of Obama-inspired health care legislation that I find chilling is the widespread use of financial incentives to bribe doctors to counsel on end-of-life options, and to recommend certain courses of medical treatment to their patients.
Through my baby-boomer husband's various health issues as a diabetic, I've learned much about dealing with doctors, doctors' medical groups, medical labs, and hospitals.
And one truism is a given in 2009: doctors and doctors' groups have little choice but to pursue the most highly-compensated options that can be rationalized in this environment of hyper-spiraling medical costs.
Don't get me wrong: this isn't a pull-the-plug-on-grandma cost-cutting measure (although I understand how hysterics could draw that conclusion). Physician counseling on end-of-life options for a terminally or critically ill patient is simply good common sense. I can't imagine any responsible doctor not gently discussing treatment/care options with a potentially dying patient.
But for our government to push doctors, via cash bonuses, to counsel all people over a certain age or with certain illnesses about treatment... or ending treatment... is grotesquely intrusive into our private lives. Too ghoulish for my taste. Frankly, it sounds like age discrimination.
Further, under President Obama's health care ideas, doctors will be incentivized... paid cash bonuses... for performing medical procedures and implementing measures in accordance with "best practices" promulgated by an 15-member government panel consisting of bureaucrats, attorneys, and doctors appointed by the White House.
Seriously... just imagine political appointees having a say in your medical treatment via cash bonuses. If that doesn't bother you under Obama, then imagine a Republican administration appointing those panel members. Imagine how George Bush, for instance, would have cut, cut, cut health care services via a panel of his conservative cronies and oil industry contributors.
Here's my point: It's a great idea for our government to issue "best practices" guidelines for medical services, preventive health measures, even health care and other counseling at all points in our lives, not just when we're dying.
But to pay doctors cash bonuses to pressure their patients toward specific treatments, plans, and procedures is:
- inappropriate meddling in the sacred relationship between doctor and patient,
- overly intrusive into patient privacy, concerns, and preferences,
- distrustful of and unfair to doctors, and
- could, indeed, allow government bureaucrats to heavily influence treatment options for patients.
I adamantly do not want my hard-working, 50-something husband, who takes five medications daily, who was diagnosed as a diabetic 11 years ago, who still has 20 pounds to lose despite his best efforts... to be counseled by a doctor forced by financial pressures to firmly nudge my husband toward the most cost-effective treatment plan as determined by politically-appointed federal bureaucrats.
It's intrusive and overly controlling. It's wrong. And it smacks of creepy social engineering.
Dump incentivizing medical practices and procedures, and leave doctors and patients to together exercise their best judgment for the circumstances.
Next up in this series of liberal blasphemies against health care reform legislation: tort reform.
Comments
As a liberal, and a diabetic, 20 years now. I am concerned about your conclusions here. I am lucky to have health insuranmce through my husbands company(as an employee) but the costs for diabetes, as you know,is already overwhelming. I also have asthma(the two most expensive illsness you can have on a on-going basis). If I were to lose my insurance, I would have to die a slow death in the current health care system. I am 50 , a mother of a 12 year old. I worry that this wuill all fall apart and someday I have to worry about eating and my health! Without either, I will not survive!
Wow Debbie. Everyone is looking at this bill as a “what’s in it for me” piece of legislation. And basically their are two lines of thought. First, there are the entitlement people who think Obamacare will solve all of our nation’s problems with medical care. Newsflash–no such legislation can ever exist, ant this bill lacks too many things to encompass the needs of everyone.
The second camp are those who want their healthcare decisions to remain a free choice issue. Obamacare certainly leave these citizens in the dust.
Between the two camps are those who realize the national budget just can’t sustain additional social spending. It’s “guns and butter” economics at it’s most essential.
Keep reading the bill. 1018 pages house other hidden bombs–like counselling families in their homes on how to raise their kids. Chilling!
Teresa, like most Republicans these days, you simplistically view all political issues as black and white, them vs. us.
Health care reform is complex, and requires careful consideration of each of its elements. I support a public plan option, but believe that a few of its elements need modifying to be fair and preserve our freedom of choices as much aspossible. Incentivizing is one of those elements.
Donna, I hear you, and share your worries about the existing health insurance system. My husband had kidney surgery in 2007, and we thought we fully understood and pre-cleared our insurance coverage and out-of-pocket expenses. We were stunned when a month or two later, we received bills for thousands more than we were told, including bills that our insurer, United Healthcare, simply refused to pay for no apparent reason. Also, excess billings for all sorts of peripheral medical services. We had no idea we had inadequate coverage until we went to use it.
Thank you for doing what must be done in my opinion about this issue. The people backing the reform package as stands will not admit big flaws. You did. This bill cannot pass if it is hyped as a flawless panacea. Most people know that is not true.
I think also that a big problem between the sides is that both actually want about the same thing. However, politics is really getting in the way. Heartland Americans opposing this bill know there are alternatives not being looked at that are more practical and cheaper. So do the politicians. But, this bill rewards certain groups. That will not work either. People know more now than ever. We see all the Pharma commercials on TV for patent drugs that do not need advertising as they are only available by prescription. Why not lower drug costs by making advertising against the law as it was before. Well, look at who is about to do a $150mm push on the reform package and you will see what is making average Americans think the things that sound ugly.
They figure if Bozeman, MT can do healthcare for 30% of the cost of conventional, then this bill is a takeover plot. Listen to this. They do not understand how this makes sense, and it does not.
Finally, I believe only a bill that neither party championed at first can pass. That takes the lobbies out and reasonable Americans on both sides all want good healthcare. Saying otherwise is not understanding people.
The much-discussed advance directives counseling bit has been more discussed than any piece of prose since “Where’s the Beef?” That portion of H.R.3200 is a subtext outlining details of an incentive feature not for all doctors, only for those who voluntarily were seeking incentives. Nothing about it is mandatory.
Currently any doctor who counsels a patient regarding advance directives is doing so pro bono, or billing his time as something else. Medicare will not pay for that counseling. That’s all.
My five years in a hospital/retirement community environment and a continuing education course in gerontology made clear that advance directives can be more important than wills, to both the patient and his family.
That said, it’s okay with me if they strike that piece for the sake of politics since explaining that to the frightened, paranoid people I have heard is like telling a white farmer in 1963 that the 1964 Civil Rights Act would not make it mandatory that his daughter would be forced to dance with a Negro at the prom.
About that panel, at this point it’s role is advisory. But sooner or later America’s runaway health care inflation will have to be brought to heel or the rest of our economy will not make any difference. As Dr. Gawande’s cover story in the June New Yorker made clear (comparing McAllen and El Paso, Texas) the vast price differences that now yawn wide in too many communities across the country must be closed. Model best practices are well-understood and followed in many places, but not enough. The worms in the economic apple are being discovered and will have to be controlled.
Coincident with the advisory panel you linked is another advisory panel, MedPac, which has been around since the Bush years charged with “studying” the same issues. Unfortunately MedPac was never given any real muscle, so this new approach is yet another attempt to accomplish the same goal.
A big part of the problem is that Medicare reimbursement rates are NOT aimed at bringing about the changes that are needed. They are, instead, yet another Congressional pork item and the legislative branch won’t surrender that oversight. (Think F-22’s that are neither needed nor wanted by anyone but our own elected representatives here in Georgia and you see what I mean.)
Runaway orders for tests, medical devices and expensive procedures of questionable medical value are part of America’s high medical bill. It would be different if the results were more impressive but they are not. We desperately need a medical care analogue to the US Postal Service, a safety net protecting even the stupid, ignorant and irresponsible as well as victims of economic disasters, whether of their own doing or not.
Nobody in Washington is interested in hurting anyone. It’s no more creepy to have a political appointee looking over my doctor’s shoulder than having an IRS agent auditing his taxes. In fact, come to think of it, from what I have read in the last six months or so, I would rather have the advisory panel than the auditor double-checking what he does. Doing anything at this point, even something that seems creepy, is better than doing nothing.
Incentives are and will be optional. Whoever wants to keep using running boards, buggy whips and hand cranks is perfectly free to continue doing so. And even if by some act of Heaven reform started next month, any measurable changes probably will not occur for five or ten years out. From what I have seen, an entire new generation of medical professionals will have to be brought into existence with a whole new approach to how medicine is practiced before fundamental improvements (price-wise) can be realized.
At this point no one is even talking about the current shortage and shrinking numbers of primary care physicians and nurses. Or the imbalance of rural versus urban services. Or the fact that two or three insurance cartels monopolize most of the country. Or that the famous “usual and customary charges” are determined by Ingenix, a subsidiary of United Health Care. How do you spell “conflict of interest”?
Sorry, Deborah. I’m tired.
John/Hoot-
Thanks for your thoughtful post. I will have to absorb most of it tomorrow.
It’s the concept of incentivizing that bothers me. Once a concept is enshrined in law, it then becomes fair game for tinkering. Today it’s mandatory, tomorrow, some of it is not. Eventually, most is mandatory. Politicians do that by design.
Also, profit-hungry medical groups can make it mandatory for their member doctors, at least here in Southern California. And almost all doctors here are part of medical groups.
If I sound a bit weary of health care coverage, it’s because we’ve had the experience of being covered by United Healthcare, through my husband’s employer, for the past five years. UHC is a prime example of acting egregiously toward those who pay premiums to them.
Theme : 6 Main Lies Have Nothing To Do With This Promising Reform / Without reform, Medicare system doomed.
If the findings of CBO over inaction had been released earlier, Ted Kennedy could’ve seen his lifetime wish come true.
Inaction cost, $9trillion over the next decade, can not be compared to the balance between estimate and outcome in a worst case of scenario, and this balance could be adjusted each year. ((Some of CBO analysis : While the costs of the financial bailouts and economic stimulus bills are staggering, they are only a fraction of the coming costs from Social Security, Medicare, and Medicaid. Over the next decade, the Congressional Budget Office (CBO) projects that each year Medicaid will expand by 7 percent, Medicare by 6 percent, and Social Security by 5 percent. These programs face a 75-year shortfall of $43 trillion–60 times greater than the gross cost of the $700 billion TARP financial bailout)). Time does not fix endless greed and energy depletion.
When the public health is also one of commodity like a house, we come to a tragic and unthinkable conclusion : As to for-profit business, the more and longer ills patients get, the more profits they make, and it will debilitate the overall economy involving education for the future, not to mention continued bankruptcy of middle class.
Of young adults ages 19 to 29, 13.2 million, or 29 percent, lacked coverage in 2007, and that implies the total of this promising reform will be cheaper than expected, I guess.
In case of an unexpected injury or ill, they might give up their learning or aspiration, in this regard, this reform means liberty, job opportunity, competitiveness for them and future.
1. The contents of savings (below) in this reform ‘have nothing to do with’ limit to medical access, rationing, tax raise, and deficit etc.
Rather, without wiping out these wastes and roots of bankruptcy for middle class, all fronts are sure to face larger financial ruin than this recession, which leads to more limit to medical access, more rationing, more tax raise, and more deficit etc than today.
$1.042trillion (cost of reform) + $245bn (cost to reflect annual pay raise of docs) = $1.287bn (actual cost of reform).
$583bn (the revenue package) + $80bn (so-called doughnut hole) + $155bn (savings from hospitals) + $167bn (ending the unnecessary subsidies for insurers) + 129bn(mandate-related fine based on shared responsibility) + $277bn (ending medical fraud, a minimum of 3% , the combined Medicare and Medicaid cost of $923.5bn per year, as of July,) = $1.391trillion + the reduced cost of ER visits (Medicare covers some 40% of the total) + the tax code on the wealthiest more reduced than originally proposed = why not ? (except for a magic pill, an outcome-based payment reform & IT effects and so forth).
As lawmakers debate how to pay for an overhaul of the nation’s health care system, a new report from The Commonwealth Fund claims that including both private and public insurance choices in a new insurance exchange would save the United States as much as $265 billion in administrative costs from 2010 to 2020.
“Health reform can help pay for itself, but both private and public insurance choices are critically important,” said Commonwealth Fund President Karen Davis, who coauthored the new report. “A public insurance plan can help drive new efficiencies in the system that will produce large cost reductions. Without a public plan, much of those potential savings will be lost.”
Unlike high fuel price and mortgage rate in recent years as the roots of great recession and bankruptcy of middle class, the severity in the high cost of health premiums has come to light lately. Similarly, in an attempt to hide these deficit-driven corruptions and wastes, the greed allies struggle to turn the savings via removing these wastes into limit to medical access, rationing, tax raise, and deficit etc.
In contrast, not to mention a wide range of consumer protection, options across state lines, this promising reform takes initiatives in more primary care docs and improved long-term care. And the bill expands coverage for mental health services, and defines what will be covered. It also prohibits co-payment charges for wellness and preventive medical care. There is no mention of rationing. The use of this term is, again, a gratuitous distraction aimed at feeding fear
2. Greedy insurers with no competitors by consolidation have nothing to do with the law of price, demand & supply.
Under the free market theory and the premise that the public health is also one of commodity like a house, if the demand decreases on a large scale, accordingly the price tends to reflect it, as in the case of house price, and it never happens for the price to spiral up. One step forward, in case the price is spiraling up, to be sure, the remaining clients should withdraw the contract or choose the other options. In practice, runaway premiums with no competitors by consolidation drive the enrollees out, and 4C + 2R (canceling, capping, cherry-picking, cash for special lobby, rationing, rapid premium hike) guarantee multiple times as much profit. Sadly, no way-out other than the prohibitive ER is allowed in America. Therefore, the victims today and tomorrow deserve long overdue protection from non-profit Government.
3. The plans to stem inflation in the House have nothing to do with crowd-out.
With the heartbreaking tears in mind (In no other industrialized country do 20,000 people die each year because they can’t afford to see doctor. Nearly 11 Million Cancer Patients Without Health Insurance), private market also needs changes and should join together to complete this reform , as promised, otherwise, the runaway premium only has itself to blame while new firms are filling the void with competitive deals.
And It can be said that fair competition starts with a fair, sustainable market value.
However, the plan in the House is designed to keep people in an employer-based health insurance system, and the public option would be offered to those for whom employer-provided insurance is not available. And job-based coverage (indirect payment), some mandate code, ample capital, the reduced exorbitant ER costs, IT base to streamline the administrative processes and trim the costs might be favorable to the private market. Over time, supposedly, the public plan will concentrate more on basic, primary cares, and the private insurers will provide their clients with differentiated services. And focus should be on the uninsured, the underinsured.
– Except For The Underinsured, The Uninsured Alone Outnumber The Entire Population In Canada –
In an attempt to avert innovation, moderation, and social responsibility, accusing essential affordability, citing take-over, will be a dirty play.
4. Profit-driven markets have nothing to do with affordable, sustainable public health.
When the public health is also one of commodity like a house, we come to a tragic and unthinkable conclusion : As to for-profit business, the more and longer ill patients get, the more profits they make, and it will debilitate the overall economy involving education for the future (Of young adults ages 19 to 29, 13.2 million, or 29 percent, lacked coverage in 2007).
Under the most wasteful structure on the planet like no coordinated preventive care program waiting until people get ill, about 50% of idle world’s best practices, a pay for each and every service reimbursement and frequent readmissions, no e-medical record and deaths, crushing litigations and the more profits via the unnecessary, risk-carrying procedures, and the most inefficient paper billing systems imaginable, overpriced pharmaceuticals, bloated insurance companies, incredible medial fraud, exorbitant costs by the tragic ER visits etc, it might be no wonder with the comprehensive, systematic reform in the pipeline, just one attitude of patient-oriented value in 10 regions has attained 16% of savings in Medicare while their quality scores are well above average.
Aside from the already allocated $583 billion and the savings of this reform package, 16% of $923.5bn (the combined Medicare and Medicaid cost per year, as of July) is around $147.76bn per year and 1.4776trillion over the next decade, and this patient-oriented value alone could be enough to meet the goal.
Please be ’sure’ to visit http://www.nytimes.com/2009/08/13/opinion/13gawande.html?hp for credible evidences !
Today, another innovative, fundamental change in payment system, or patient’s outcome based payment reform that is able to turn the profit-oriented malpractices and volume into the patient-oriented value and quality is waiting for a final decision.
Now that Minnesota spends “20 percent” less per patient than the national average and 31 percent less than in the highest cost state, under a pay for patient’s outcome pack, this promising reform could be successful along the way, I believe.
Aside from the already allocated $583 billion and the savings of this reform package, “20%” of $923.5bn (the combined Medicare and Medicaid cost per year, as of July) is around $184.7bn per year and 1.847trillion over the next decade, and this patient-oriented value alone could be sufficient to meet the goal.
5. Inflation-driven greedy allies backed by the insurers have nothing to do with deficit-neutral.
When some part of our body is ailing seriously, we are going to lose competitiveness, equally, when some part of a nation is ailing servery, it is going to loose competitiveness, too. In case somebody in the house gets ill, health will be put over house, in practice.
6. The analyses of CBO have nothing to do with common sense and practice.
Costs of Preventable Chronic Disease account for around 75% of the nation’s $2.4 trillion medical care costs. U.S. health care spending is also expected to double in the next 10 years. and they are largely preventable — 80 percent of the risk factors are behavior-related.
Unlike the analyses of CBO, world-wide outstanding public programs put heavier emphasis on preventive program equally, and preventable swine flu pandemic is expected to cost about $2trillion dollars world-wide for the lack of prepared vaccines. (Genes included in the new swine flu have been circulating undetected in pigs for at least a decade, according to a team led by Rebecca Garten of the federal Centers for Disease Control and Prevention who have sequenced the genomes of more than 50 samples of the virus).
If CBO asks the profit-driven interests about why they have hindered the budget request for preventive program in Medicare and Medicaid, they will say, ” just look at the health Katrina special lobbying has made, the more and longer ills, the more profits, we are professional, and we are obstructing this reform right now, too ” .
7. Conclusion : The public health is a fundamental human right.
As I said above, patient-oriented value alone could be enough to meet the goal, and another innovative, fundamental change in payment system, or patient’s outcome based payment reform that is able to turn the profit-oriented malpractices and volume into the patient-oriented value and quality is waiting for a final decision.
If At least, some media pay attention to this flower of reform, people will feel empty as the past and current discussion has been time-consuming for sure.
Thank You !
Take care of me, take care of me! Its true that an overwhelming number of Americans do not make intelligent decisions, on a daily basis, regarding core areas of what should be personal responsibiity, like health and financial matters. How many lived above their means for the past ten years? How many pursue unhealthy life styles? When was the last time we each took account of the last dollar we saved or the last time we went for a healthy walk?
After years of bad personal decisions it is no surprise that many need, dare I say want, to be taken care of, even at the expense of giving up their own personal freedom. Two wrongs don’t make it right.
Yes we can take personal responsibilty for our own welfare.
While I agree with much of what you say, I disagree that Republicans are merely being obstructionist. I won’t dwell on it, though, other than to say that the GOP has its own plan and perhaps a hybrid of the best of both proposals would generate support.
What I wanted to comment on, however, is the concept of medical standards. I’m actually in favor of a “best practices” measure, but not when it comes to the dispensation of health care at the basic doctor-patient level. I think a “best practices” policy or at the very least a set of standards developed by a panel of experts would go a long way toward creating meaningful tort reform, especially if there was a list of fines to accompany the transgressions of those standards or practices. IOW, if a doctor gets sued, and it is revealed that he/she violated a certain standard or practice, there would be a crib sheet of penalties for transgressions. If a person commits a crime, a judge must consult the “sentencing guidelines” when determining a penalty. The same should go for civil courts, and — especially when it comes to medical malpractice — a best practices model based on accepted standards that itemizes penalties for breaking those standards or practices would help ensure that “statement judgments” are a thing of the past. Certainly, the severity of the transgression should be factored into the final decision, but it makes more sense to strip a doctor of his license to practice medicine than it does to award a billion dollars to an aggrieved patient. Certainly, the patient needs to have enough to care for his injuries — especially if it’s a life-altering one — but ensuring that the doctor is unable to repeat his offense should be one of the court’s foremost concerns.
Excellent commentary, John Ballard.
The Health Care Plan(s) are simply too expensive at this time. In 8 months our nation has quadrupled our deficit; this worries me a lot, but it worries my grown children even more.
They ask, “Why can’t we buy health insurance the way each of us buys auto insurance, finding the package that’s best for each of us?” Plus they ask why reform healthcare when 80%plus of Americans are satisfied with what they have?
I have to admit…I agree with them. Pelosi, Reid, and Obama have not made a strong case for health care reform.