Thursday, June 29, 2006

Another Slant on Healthy Brits

In response to the posting The Hazards of Comparison, long-time friend from Kentucky days Betty Jean Hisle reports still another slant on why Brits seem to be healthier than Americans:

Bruce K. Johnson, a former contributing columnist to The Lexington Herald and now professor of economics at Centre College, recently referenced Paul Krugman's NY Times commentary of May 14.

Johnson’s thesis is that contrary to popular opinion, the British are much healthier than we in the US not because they have universal health
insurance, but because they walk so much more than most Americans.

He bases his opinion on the fact that he loses 10 or 12 pounds each time he directs a student program in London. He points out that Londoners make 1/3 of their journeys around London on foot.

Betty Jean says that she intends to share Johnson’s column with two granddaughters who will go with her to London for two weeks in late August when they complain of too much walking.

Friday, June 23, 2006

Single Source versus Single Payer

The posting No Single Payer in Our Time stimulated the below from Bob Sigmond, one of the old lions of health care who dates back to before most people who read this were born and who clearly hasn’t lost anything to the passing years.

I think you are confusing reform based on a single payer with reform based ON A SINGLE SOURCE OF PAYMENT.

In my opinion, a single payer is a very good idea in every community, a relatively simple adjustment in our financing system that would make a great deal of difference. Also, not that hard to make the change. Actually, in many communities, we are moving very close to a single payer WITH MULTIPLE SOURCES OF PAYMENT.

Consider those Blue Plans which are the payer for local subscribers, patients who are beneficiaries of national Blue accounts, Medicaid, Medicare, FEP, and who knows what else. In some places, the Blue Plan is the single payer except for the commercial insurance carriers who would be smart to sign up with the Blue Plan to do their paying obligations [other than to the insured patients directly which is the traditional way that commercial insurers should pay] on a contract basis that would be advantageous to both the insurer and the Blue plan, and would save the insurer a lot of money and headaches, and greatly simplify the life of provider CFO's. Why not?

Now, if the Blue Plan converts to a semi-governmental governance and management structure like a health authority like Gail Warden has created in Wayne County (Michigan), then we have a pattern of a single payer which would have a great deal of ability to influence how the money is spent, while it does what the plan is doing now, and that is administering a lot of different payment arrangements for a lot of different sources of the money.

That was really Walt McNerney's vision when he invented the intermediary relationship for Medicare, which he thought would apply to Medicaid as well, and without the insurers getting involved as intermediary payer competitors in the process, since they had no idea of what that is all about. It did not work out that way, but it could.

Don't give up on single payer just because everyone is confused about what single payer is about: i.e., the payment process. The sources of payment are not so important as how the payment process works, and the lack of a single payer process is probably the main weakness of our system.

Thursday, June 22, 2006

Back to Basics

The most recent group of postings stimulated the following from personal friend Gail Price:

I truly believe nothing good will happen to change health care errors and lack of clarity and fairness until hospitals are no longer a for-profit business; back when I was working as a Master's level nurse and early on as a Ph.D. psychologist, virtually all my colleagues/friends told of reducing fees for patients, giving them extra time on the phone (no fees) if needed. Hospitals were more concerned with life and good care and all hell broke loose if someone made a mistake. I once made one in the midst of an operation and the surgeon told me loud and clear for all to hear that if I ever did that again I would not be allowed to assist. Guess what: I never did that again. And it all had nothing to do with money; it had to do with loving one's work and loving one's patients. Now patients are merely dollar signs, not people. Witness the struggle nurses have trying to get adequate staffing numbers. An exhausted nurse is going to neglect patients merely because she has so little energy and concentration. I do wish someone would come out loud and clear against this for-profit-care we now have with most of the concern going to the "shareholders." It became criminal a long time ago; and the public knows little about what is truly going on. Some few years ago I was in California visiting friends and returning from a conference in LA to SF. I was rear-ended by a truck and had sufficient discomfort that my friends wanted me to go the ER at Kaiser (their provider who provided excellent care). I waited over two hours on an uncomfortable stretcher and when a doctor finally came into the room he walked across it and stood there and asked me a few questions, refusing to examine me or get an x-ray, even though I told him I had a mild scoliosis. In less than ten minutes he was out of the room. His recommendation: go home and get in my friends' outdoor hot tub. I make every effort to stay far away from hospitals.

Wednesday, June 21, 2006

The Toyota Example

Some time ago, the Institute for Healthcare Improvement promoted a program called Going Lean in Health Care that encouraged hospitals to implement management approaches that had worked so well for Toyota, the Japanese car maker.

Toyota is one of the companies that has spread financial chaos among the previously secure and successful American automobile manufacturers by finding ways to make cars that are better and less expensive.

The U.S. health care establishment has thought itself immune from any such competition.

That may not be so. The Toronto Saturday Star of June 17, 2006 carried a front page article headlined India offers surgery in a hurry, featuring one Richard Johnson of Nova Scotia who went to India for heart surgery.

It seems that Johnson’s doctor was treating his chest pain “with cholesterol pills and a wait-and-see attitude.” Johnson had been on a “months-long waiting list for an angiography.” When his housekeeper’s husband, also being treated for chest pain, had a heart attack, Johnson decided not to wait any longer. He went to the Web and found Escorts Heart Institute and Research Center in New Delhi, India. Escorts is directed by Dr. Naresh Trehan, a New York University-trained cardiac surgeon.

Without bothering to make advance arrangements, Johnson hopped a plane to New Delhi, checked in at a hotel across the street from Escorts and presented himself to the hospital the next morning at 6:00 a.m. By 8:00 a.m. he’d had an echocardiogram and that afternoon had a stent inserted to open his blocked artery. He’s had a good recovery. Total cost for his 10-day stay in India, including a side trip to the Taj Mahal in a chauffeur-driven Mercedes was $6,000 U.S. The same procedures in the U.S. could easily run five times that.

The Confederation of Indian Industry reports that about 200,000 foreigners went to India for medical and dental treatment last year, and that the number is growing at some 15% per year. The New York office of McKinsey Consulting predicts that “medical tourism” in India will generate $2.28 billion in revenue by 2012.

It seems that U.S. health care may not be immune to foreign competition after all.

Tuesday, June 20, 2006

Time to Get Over It

The June 15, 2006 newspapers carried reports of an investigation by the Institute of Medicine on the state of Emergency Rooms in U.S. Hospitals. To no one’s surprise, the investigation found that Emergency Rooms are overcrowded and overwhelmed.

How can it be that a wealthy nation that devotes over one seventh of its wealth to health care, and boasts the largest, most elaborate, most abundantly financed hospitals in the world finds this prominent service “at the breaking point?”

At the risk of being immodest, I think I know the reason. Within the culture of the U.S. system of health care, emergency rooms have never been popular. There are two reasons. Hospitals don’t like them because they attract patients without the means to pay. Doctors don’t like them because they compete with private practice.

The article I read in The Boston Globe quoted Dr. Arthur Kellerman of Emory University as pointing out that Emergency Room care is “the only medical care to which Americans have a legal right.” So once a patient shows up, the hospital has to provide care whether the patient can pay or not.

Doctors get upset not only because they lose fees when their patients go to the ER instead of to their offices, but also because they often lose patients that way. Once caught up in the ER process, patients get referred to whoever happens to be on call and may well just stick with that physician and never go back to the one they were seeing before.

In addition to all that, care received in the ER is identified more with the hospital than with the medical profession – something not at all appreciated in the culture of health care.

All of that may be understandable, but that doesn’t make it excusable. ERs have become a central feature of our health care system. They may not like them, but it’s time for hospitals to get over it and operate their ERs properly.

Monday, June 12, 2006

Who Should Manage Care?

A front-page story in its June 11, 2006 issue, the Boston Sunday Globe, under the byline of reporter Christopher Rowland, was about one Dr. Stephen A. Hoffman of Framingham, MA who admitted to cheating the Tufts Health Plan. It seems that the Plan will only pay for 10 pills a month of the sleep aid drug Lunesta. Dr. Hoffman thought his patient needed more than that, so he wrote a second prescription for the patient’s husband. He conceded that this was not the first time he had done such a thing to get around insurance restrictions.

The general theme of the story was the frustration of primary-care physicians with “increasingly restrictive rules imposed by health insurance companies in an effort to reduce healthcare costs.”

The story went on to talk about how these rules and other bureaucratic hurdles are discouraging doctors from specializing in primary care and to confirm that what Dr. Hoffman had done was not condoned by governmental agencies or professional bodies.

All of which raises a straightforward question. Should healthcare be managed or should every physician be at liberty to treat patients in whatever way he or she sees fit?

If healthcare is not to be managed, then the prospects of doing anything about cost and quality are dim indeed.

If healthcare is to be managed, a second question arises: who should do it?

It seems clear to me that it ought to be done by the providers themselves (e.g., doctors and hospitals). But with the exception of the few remaining integrated HMO’s, like Kaiser of California, who operate their own insurance plans, employ their own doctors and run their own hospitals, they have so far been unwilling to do so.

Until that changes, the insurance companies have little choice but to do it in ways that are necessarily clumsy and insensitive to individual cases.

Thursday, June 08, 2006

IT and Healthcare - Not There Yet

Dr. Glen Steele Jr., CEO of Geisinger Health System in Danville, Pa, has received the 2006 CEO IT Achievement Award from the publication Modern Healthcare and the Healthcare Information and Management System Society.

Dr. Steele is a highly regarded healthcare executive and by all accounts has been an excellent CEO for Geisinger. He and Geisinger are to be congratulated for the achievements that led to this important recognition.

The award was featured in a special supplement to the June 5, 2006 issue of Modern Healthcare.

As I read through the material, I was reminded once again of how difficult it continues to be for healthcare institutions to make effective use of information technology.

That difficulty was illustrated by Frank Richards, the Chief Information Officer at Geisinger, who characterized Dr. Steele as “someone with a real vision of where IT could take healthcare.”

The notion that IT will take healthcare somewhere seems to be the prevailing perception within the health care establishment.

An alternative approach would be to develop a vision of where healthcare should go and how IT could help it get there.

There is a big difference. In following the first approach, healthcare institutions have spent vast sums of money implementing IT in the hope that something good would come of it.

Under the alternative, it would be possible to evaluate proposed investments in IT against the worth of the goal being pursued and, where the decision was to proceed, to later determine whether or not the goal had been achieved.

One hopes that some day the latter approach will be adopted. But it seems that we are not there yet.

Monday, June 05, 2006

No Single-Payer in Our Time

More than thirty years ago, I noted that private enterprise economies, of which the U.S. is one, adopt public schemes for financing social services when the private sector proves unable to fund those services at a satisfactory level.

Since the private sector of health care in the U.S. was then more than adequately funded, I concluded that we didn't have the problem and so we wouldn't get the solution. In other words, no national health insurance.

We don’t talk about national health insurance anymore. Now we call it single-payer. But other than that, the situation seems to me to be unchanged.

Adequate funding leaves single-payer without a political constituency. In the U.S., the aged and the poor are already insured in the public sector by Medicare and Medicaid. Much of the employed population gets its health insurance through employee benefit plans.

There are, of course, the uninsured. While they are large in numbers (reportedly over 40 million) and a public embarrassment, they are neither visibly suffering nor politically active. They clearly would be better off if they were insured and they undoubtedly would like to be, but they are not marching in the streets.

Hospitals complain continually about inadequate reimbursement, as one might expect, but are in fact flush with money, as shown by their profit margins and their ambitious construction programs. Doctors are being squeezed, but still live well. Pharmaceutical and other health-related businesses are prospering.

If there are any that are “visibly suffering,” it would be the governments and employers that are bearing the high and rising cost of health insurance.

Single-payer would expand the health insurance role of government and, therefore, increase its “suffering” accordingly.

Employers complain about the burden of funding employee health benefits. But they show few signs of wanting government to take it off their hands. No doubt they realize that government would have to get the money by means of some kind of assessment (not even the most enthusiastic borrow-and-spend Republican denies that) and there is no assurance that the amount would be less than what employers are now paying for private coverage.

Conceptually, there may be a number of good arguments to be made in favor of single-payer. But if it isn’t going to happen, we need to forget about it and put our minds to devising other solutions for the problems of our health care system.

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