Friday, February 26, 2010

No Single Payer in Our Time

Despite the determined persistence of its advocates, we are not likely to see a single payer program adopted in the United States in our time.

There are several reasons. Perhaps the most important is our high level of health care spending, which provides generously for those who have health insurance. The larger portion of premiums are being paid by the employer or by government and the insured are for the most part satisfied with the coverage they have.

With government budgets already strained by the high cost of health care, all of this makes it hard to convince the insured that they would benefit from nationalizing their health insurance and makes it relatively easy to make the case that single payer might well leave them worse off – if for no other reason than the taxes required to support universal health care.

That leaves the proponents with the need to justify their cause on moral grounds; i.e., that as a society we have an obligation to help those who cannot obtain health insurance or are unable to afford it. But that argument is weakened by government-supported safety-net hospitals and clinics in our larger cities and by the legal obligation of hospitals to treat all who appear in their emergency rooms, regardless of ability to pay. While the care provided by these facilities may not always measure up to that received by the insured, it is good enough to prevent the sort of heart-rending stories that might energize the public to support a more comprehensive public program.

Then there is the political ineffectiveness of the uninsured population. It is to a large extent a transient, politically inactive group, some of whom are uninsured by choice. One hears of people marching for this cause and that, but never for national health insurance.

And all this exists in the context of a political culture that includes a deep-seated distrust of government.

Adoption of single payer would be a political act. However, political conditions in the United States do not favor it and the chances of its happening are somewhere between slim and none.

Wednesday, February 10, 2010

Chaos and Organization in Health Care

If the health care delivery system is going to deal effectively with the issues of cost and quality, it will have to get organized.

That is the theme of a book I have just finished reading. Its title is Chaos and Organization in Health Care. It was written by Dr. James Mongan, CEO of Partners Health Care System (now retired) and Dr. Thomas Lee, Network President, Partners HealthCare System. Partners Health Care System consists of the Massachusetts General Hospital, Brigham and Womens Hospital, and several other facilities in the Boston area.

I read the book at the urging of fellow parishioner Brian Baldwin, to whom I am most grateful.

This blog was started as a forum for discussion of what a reformed health care system should look like. To the best of my knowledge, Mongan and Lee have presented for the first time a coherent proposal on that topic.

As a basis for doing so, the authors have displayed the current health care delivery system along a graph with two axes – one showing a range of payment methods and the other a range of organizational forms. At one extreme is the solo practitioner paid fee-for-service (chaos). At the other is a fully integrated delivery system like the Kaiser HMO or the Geisinger Clinic in Pennsylvania, paid by means of capitation (organization).

Their proposal is that the system of health care delivery and finance ought to move away from chaos and towards organization. They point out that it has moved a considerable distance in that direction already, but that the pace ought to be accelerated.

I couldn’t have said it better myself.

If President Obama and the US Congress would propose such a program, that would be something I could enthusiastically support.

Thursday, February 04, 2010


Until you have tried to develop a computer application, you will not appreciate the number of steps involved in the most mundane of human activity. Take, for example, paying a bill. That routine chore involves getting access to the bill, a checkbook, and a pen, picking up the pen, filling out the several blanks on the check, etc., etc., etc. If you were to program a computerized robot to pay bills, you would have to identify all of those steps and give the computer specific instructions on how to carry out each one.

If you want to computerize a more complex function, like managing a personal bank account, it is important at the beginning to define clearly what it is you are trying to do and then confine the project to that. It is easy to become enamored with the capabilities of the computer and complexify the situation by wandering off into the other things it is theoretically possible to do, even though they were not part of the original goal.

I am reading Chaos and Organization in Health Care by Lee and Mongan of Massachusetts General Hospital. Beginning on page 76 is a section entitled EMRs (the acronym for Electronic; i.e., computerized Medical Records). Here are some of the things they mention that EMRs can do:

Collect and store information about patients.
Give clinicians the ability to retrieve these data when needed.
Order tests and medications.
Guide physicians in the safest and most reliable choices.
Help physicians keep track of patients’ needs.
Communicate with other providers.
Communicate with patients.
Help physicians comply with preventive and chronic care guidelines.

In order to computerize these functions, each requires a much more specific definition. Then all the steps involved in each would have to be identified and their sequence charted out.

Can you imagine trying to do that? It would be hard to find a wall large enough to do it on.

No wonder hospitals have been so slow to adopt the EMR.

This page is powered by Blogger. Isn't yours?

FREE counter and Web statistics from sitetracker.com