Bob, thanks, I am adding this item to my file on "polls" that I've kept since the 1970's.
The results have been amazingly consistent - high numbers of people satisfied with their OWN insurance, their OWN doctors, and their OWN costs - and, simultaneously, high numbers of people who say that there is a "crisis" in health care.
So if the majority are satisfied, where is the "crisis" exactly?
Best explanation I've seen is that the breathless media reporting has created the impression in many people that everyone else is suffering.
This is not to say that the US health care system/industry doesn't need some long-overdue fixing-up. It does. However, the required fixing-up would seem to be less than a radical overhaul, if the results of public-opinion polls over a 30+ year period are any indicator.
Just my 2 cents.
You can download the full report at this site.
http://www.kff.org/kaiserpolls/
p...mr101606pkg.cfm
Some of the curiousities of the poll, 75% reported no problem in paying medical bills while 25% said they had problems. Of the 25% with problems, 69% had health insurance, the remaining 31% did not.
So those with health insurance have more difficulty paying medical bills than those who do not.
Go figure.
Even more curious, 11% of those having problems paying medical bills have incomes in xs of $75k.
We have the best healthcare system in the world.
Making it any cheaper/free would just make things worse.
Well that's the biggest problem we face with fixing the health care system in the US. There are just way too many healthy people.
Now while I don't have any numbers to back me up, I'll bet that the number of healthy people out number the sick by at least 10 to 1.
Then if you take into account the number of people on Medicare, those results don't surprise me at all.
I blogged on this topic back in April of this year.
Until you get really sick, you have no idea just how bad our health care system really is.
I sure would love to see a demographic break down of those who were polled.
As one who has been both an inpatient and outpatient numerous times over the last 12 years in a New York City academic medical center and a local community hospital, I generally found my experiences ranged from very good to excellent. The weakest part of the system from my perspective was the billing and payment part. Due to providers sometimes not submitting information correctly to insurers, I would get bills that I was not liable for or, in one case, had already been paid to the WRONG HOSPITAL. One time, regarding a hospital stay, while I called ahead of time to alert my insurer as my policy requires (and the hospital called as well), the information somewhow never got to the right place in the insurer's organization, and they tried to bill me for a $500 penalty. It was a bureaucratic hassle to straighten that out. How many businesses would tell a customer with a straight face that because we screwed up, it's YOUR problem and you owe us more money?
the biggest problem we face with fixing the health care system in the US. There are just way too many healthy people
You are kidding, right? Too many people are healthy?
I'll bet that the number of healthy people out number the sick by at least 10 to 1.
More like 5:1. Claim stats by carriers show 20% of the covered participants generate 80% of the claims.
Until you get really sick, you have no idea just how bad our health care system really is.
I suspect most people would disagree. When you get really sick you find out just how well it performs. Countless lives are saved that would not have been so 20 years ago.
Like I said Bob, I didn't have any stats, but I wonder how many of that "20% of the covered participants generate 80% of the claims", are on Medicare, with supplemental insurance.
It is still important to know what the demographic make of those polled is, before drawing any firm conclusions from this report.
And I am ashamed to admit, that I misquoted myself. I should have said
Until you get really sick, you have no idea just how bad your health insurance really is.That was what my post in April was about.
And you only have to look at the class action law suit being filed on behalf of all CA hospitals or the post you did a month ago, to know how true that is. (And there are many more similar instances which have been reported.)
Although the latter wasn't due to any shenanigans by the insurance company, it does point out a flaw in our health care system, that many are unaware of or unprepared for.
Oh, and one last point, I wonder how many of the 57% of those satisfied with the cost of health care have to pay for it themselves or even know how much it costs?
Now I'm really confused Bob. I just went to the link you referenced in your post, and couldn't find the poll you referenced.
But I did find the following quote in this link from the same Prescription for Change ABC News report.
As part of the series, ABC News, the Kaiser Family Foundation and USA Today polled people across the country. Just 44 percent said they are satisfied with the overall quality of health care, and only 18 percent were satisfied with the cost.
Doesn't that contradict what you are reporting?
how many of that "20% of the covered participants generate 80% of the claims", are on Medicare, with supplemental insurance.
None
how many of the 57% of those satisfied with the cost of health care have to pay for it themselves
I have no idea, nor do I see what it matters. If it were free there would still be dissatisfaction.
I just went to the link you referenced in your post, and couldn't find the poll you referenced
You must have neglected to download the summary & chartpack. The graph is on page 8.
Marc,
All you have to do is click on Bob's link, then click on the "Summary & Chartpack" pdf and you'll see the report. I don't know if this will work, but here's the link to the report
http://www.kff.org/kaiserpolls/u...upload/
7572.pdf
The report does say that 54% are dissatisfied with the quality of care in the nation. But it also states that at the same time, 88% are satisified with their own health insurance coverage, and 89% are satisfied with the quality of the care they receive.
Seems like a disconnect. I'm sure the intial question was a vague question. Then when they started asking more detailed & personal questions, we see the true feelings.
Just shows how propaganda works. If you say it long enough (health care in this country stinks, we need universal health care, blah, blah, blah) people start believing it. That is of course until you ask them about their personal situation or share how care would change if it were a universal system.
Reminds me of how everyone thinks Congress is full of crooks, except for their Congressman.
1. The survey needlessly confuses the reader on pages 7 and 8. I doubt this was done on purpose, but consider:
On page 7, the "dissatisfied" responses are in black.
On page 8, the "satisfied" responses are in black.
2. The survey confirms important disconnects that many other surveys over the years have also found.
2(a)Disconnect about cost of care
In the entire country 80% say "dissatisfied"
For one's own family 57% say "satisfied"
Well, if 7 out of 12 people are satisfied with their own costs, how can 80% be dissatisfied with others' costs? My answer: the breathless media regularly reports there is a national health care cost crisis and survey respondents are just feeding back that point of view. But where they have personal knowledge, 57% report satisfaction. Does this mean there isn't a cost problem? No. But it does mean that most people are insulated from that problem as matters stand. The looming problem is the erosion of that insulation (i.e., companies peeling back their benefit plans and/or raising contributions) which will expose more and more people to high health care costs.
2(b) Disconnect about quality
In the entire country 54% of people say "dissatisfied"
For one's own family, 89% say "satisfied"
I think this result also reflects the difference between what the breathless media reports, and what people personally experience. There is a significant disconnect.
Kaiser points out these disconnects in their summary remarks, but apparently has not inquired why they exist and offer no other thoughts about them. IMO, that is intellectual laziness. The disconnect is an important finding - and it is a recurring finding - that deserves to be understood. Nothing here about it. Very disappointing. BTW, I think the recurrence of this disconnect is evidence that the breathless media have consistently bungled one of the biggest social stories of our times.
3. On page 18 we see that by a margin of 68% to 32%, survey respondents favor providing health care over holding down taxes. However Kaiser does not state the incomes of the respondents. Keep in mind that taxpayers below the 50th percentile of income pay only about 3% of all income taxes - those above the 50th percentile pay about 97%. If a significant number of respondents are low-income, then they are voting in favor of taxing other people for their benefit. I am surprised that Kaiser would publish such a fragmentary and ill-defined result.
4. Pages 20 and 21 report essentially the same disconnect as noted in item (2) above, which serves to drive home not only the truth of the disconnect, but its magnitude.
On page 20, we read that 56% favor universal health care over the present system.
And on page 21 we see respondents' expectations for their own families under a universal system, in these key categories:
COST 71% say "same or worse"
ACCESS 78% say "same or worse"
QUALITY 82% say "same or worse"
CHOICE 83% say "same or worse"
Are we now absolutely clear about why we want a universal system? Crystal?
My take, FWIW, is that this survey truly reveals the degree of satisfaction with the status quo, which in turn suggests a difficult uphill battle facing universal-system advocates.
Boy! You guys did a lot more evaluation than I expected.
I do agree there is a disconnect, but it has more to do with who is being polled.
I actually believe the first poll. Most people are satisfied with their health care, because most people are healthy. They typically only need care for routine stuff, and that seldom presents a problem even if you have to wait for an appointment.
I also believe most people are satisfied with the cost, because they don't have to pay much for it. And they're especially satisfied after hearing all the stories in the media about the rising health care costs.
I just think that if you asked just the sick or those that have to purchase health care on their own, you would get entirely different results.
Marc, you never cease to amaze me.
OK, here are some of my predictions:
If you only polled women who were beaten by their husbands you would get an entirely different result in a poll on good marriages.
If you only poll homeless people you will get an entirely different view of the economy.
If you only poll victims of violence you will get different results when quizzed about crime in America.
If you only poll homosexuals you will get an entirely different answer to the question "what attracts you about the opposite sex?"
Someone once said a recession is when someone else is out of work, but a depression is when you are out of work.
It also says that better than 505 would prefer to have a national health plan.
Coyote, you note that the survey reports "better than 505 would prefer to have a national health plan."
Yes it does report that.
Now please go back and study pages 20 and 21.
On page 20, you find that 56% favor universal health care over the present system. Just as you note.
And on page 21 you find the SAME respondents' expectations for their OWN families under a universal system:
COST - 71% expect "same or worse"
ACCESS - 78% expect "same or worse"
QUALITY - 82% expect "same or worse"
CHOICE - 83% expect "same or worse"
coyote, why do you think 56% say they favor a universal health plan when so many more of them expect that it will not make anything better for them and may even make things worse?
Any ideas?
Sorry, but the poll does say that 56% favor Universal Health care. I did not do the poll or compile the numbers. Was the question ask why they prefer a Universal plan?
Coyote,
How in the world did you make your way over to this blog? I think some of us have had enough of you on the insurance forum. In any event, the survey DOES sate that 56% prefer a universal plan. It goes on to say that when informed of the challenges, limitatations and costs of such a plan, a third or less would choose a universal health plan.
You see, when asked the generic question about a universal health plan, 56% said heck yeah. After they were EDUCATED, a third or less said heck yeah. That means 67% or more said heck no.
I know that may be hard for you to grasp, but facts are facts.
Almost forgot about this post.
I have to admit Bob, you got me on the polling demographics, but that just proves my point. You really need a break down to know how viable the poll is. But I digress.
And smansfield, you state
After they were EDUCATED, a third or less said heck yeah. That means 67% or more said heck no.
I wonder how many were EDUCATED about the problems with our current health care system. Like for instance,
1. If you get sick, and lose your job, you won't be able to buy health insurance at any cost once your COBRA runs out. And that assumes you can afford to purchase continuing coverage under COBRA after losing your job.
2. You are at risk for losing your home and life savings should you get sick, and not be able to afford to purchase health insurance.
Almost forgot about this post.
The beauty of the HaloScan Dashboard 
you won't be able to buy health insurance at any cost once your COBRA runs out
This is incorrect; see: HIPAA.
Understanding that this is a free nation we are free to debate where ever we want. Yes is the blog valid, by asking different questions could the 1/3 turn into the 2/3rds? I try to pose a poll on another forum, that went if you had a choice between no insurance and being part of a national health plan, would you acept the national health plan yes or no. This poll was rejected because the majority on this forum did not want to hear a yes answer.
This is incorrect; see: HIPAA.
Yeah, I know! That was a bit of poetic license.
Still as Bob pointed out in another comment it can be as much as 3x as expensive as the original policy. Even in CA it is 70% more expensive, the one exception being Kaiser Permanente.
But even then, health insurance is not cheap, as I am sure you know. It is difficult for most families to afford when they are working, even without the extra added cost, let alone when they're not.
Which is why there is such an uproar by many people.
Marc,
Bob already corrected you on point 1 so there's no need to beat a man while he's down.
My only question is where does it state in the Constitution that health care is a "right"? As for not being able to afford coverage, I beg to differ. I know many without coverage who CHOOSE this option. Yes, they say they can't afford it while driving 2 new vehicles, living in a high priced home, having cable tv, cell phones, eating out 3-4 times a week, etc.
They choose to not sacrifice in other areas. If they REALLY wanted coverage, they would cut back and make sacrifices. But because they don't want to be inconvenienced, they say they can't afford coverage.
As for those earning a small wage, there is public assistance. In addition, they may be earning a small wage due to life choices made early on. Needless to say, I don't feel it is my responsibility to pay for your health insurance with my tax dollars. I think I pay enough as it is.
health insurance is not cheap
Neither are organ transplants, chemotherapy, treatment of head & spinal cord injuries, burn treatment, premature babies . . .
If it were cheap it would not be worth the paper it was written on.
But it can be affordable when there is a proper evaluation & transfer of risk. As in my latest post, if you want ingrown toenail & dandruff insurance expect to pay a lot. But if you are willing to shoulder the risk for the first $5000 - $10,000 of a claim you can get coverage at a reasonable price and still have ample coverage for the major things.
This assumes you are healthy.
Repeat drunk drivers, if they can get insurance, pay a lot more than sober, safe drivers. Those who cannot manage their money pay a lot more when they need to borrow funds than those who are good stewards of their money. Good workers get promotions & raises while lazy workers get fired.
That is the way the world works.
If you think everyone should pay the same for health insurance, regardless of their risk profile, then maybe we need to start a campaign so everyone can get a loan at Prime + 3% regardless of ability to repay the loan. And everyone gets to keep their job for life and has guaranteed 2% raises, even if they never show up to work. And drunk drivers . . .
need to start a campaign so everyone can get a loan at Prime + 3% regardless of ability to repay the loan. And everyone gets to keep their job for life and has guaranteed 2% raises,
There you go again with the ... analogies. We're not talking about raises for everyone, or the cost of loans, we're talking about HEALTH insurance.
I suppose a better idea, would be to say to all the sick people, if you can't afford health care, or you don't have insurance, that's too bad. If your body can't cure yourself expect to die.
In the mean time if you want to run around spreading your disease to all your neighbors, well then.... I guess that's what the refer to as "the survival of the fittest!"
Edited By Siteowner
Marc:
Because you're a longtime IB reader & (usually) thoughtful commenter, I'll give you a break this time.
We work very hard here at IB to keep the discussion civil. I encourage lively debate, but ad hominems are a definite no-no. Please respect that.
Thanx!
An ad hominem fallacy consists of asserting that someone's argument is wrong and/or he is wrong to argue at all purely because of something discreditable/not-authoritative about the person or those persons cited by him rather than addressing the soundness of the argument itself.
While I can respect the fact you don't like how I have categorized the analogies presented here, I do take offense that I have some how made that an attack against the creditablity of you or Bob.
I have provided reasons in at least two instances why I think the analogies are "in appropriate", and in neither case have those reasons been directed against the credibility of either you or Bob.
My response should have been anticipated.
--This post is only meant for your or Bob's eyes, but if you wish to post it, that is your decisions.--
Perhaps "inappropriate" would have been a better choice.
You're better than that, Marc; 'nuff said?
Obviously I felt the analogies were compatible or I would not have used them.
Health insurance for all, regardless of their risk profile, appears to be the basic premise of your (Marc) argument. That is not a problem. In some areas health insurance IS readily available for all, regardless of their pre-ex conditions. Health insurance for all comes with a price. Either you charge those with pre-ex conditions more than you charge someone in good health; or you spread the risk of the "unhealthy" over all participants and charge everyone more.
Which way is fair?
I suspect those who are paying to subsidize the poorer risks would object. No, it is not a suspicion, it is a fact.
So the analogy of charging everyone the same for auto insurance, regardless of their driving history; or everyone the same for a loan, regardless of their financial history; or granting everyone job security & raises regardless of their work ethic was a compatible analogy.
I suppose it depends on whose ox is being gored as to whether you think the kind of analogies are accurate or not.
One key difference between driving history, financial management, and health status is the role of luck and the randomness of life. Not all babies are born perfectly healthy, some children are diagnosed with cancer, people get in car accidents caused by drunk drivers, heart disease can be inherited despite wonderful diet and exercise routines, etc. For these reasons, one could argue for health insurance based on community rating even though that means the healthy will pay more than they would under a medical underwriting model.
At the very least, there should be assigned risk pools to handle these cases at subsidized (by taxpayers) rates, though you certainly should not be allowed to go without insurance and then expect to sign up after you get sick. I think, by and large, the Massachusetts effort is a sensible approach to get everyone or nearly everyone covered and end the free riding that drives up hospital costs.
I have never said that everyone should pay the same, and did address how those with unhealthy life styles or poor driving records could be forced to pay more in a comment on the other posts Worth Mentioning.
The principle difference between health care and all the other analogies is we don't have nearly as much control over our health as we do our driving record, and our ability to get a loan.
What about those people who do lead a healthy life style? Is it fair for them to pay more just because they got sick?
And is it also fair for someone who has had health insurance for years, but by virtue of losing his job has to pay twice as much, or even more in some cases, simply because they got sick, and now has to purchase that insurance on their own.
I realize that no one ever said life was going to be fair, but every other industrialized country in the world recognizes that health care needs to be treated differently then everything else.
Only the US treats health care like any other commodity that is "distributed according to the ability to pay, rather then as a social service distributed according to need."
You're right I don't like the current system. I think it is unfair, and discriminates against those that are sick, but neither do I equate it with the purchase of cars, homes or any other commodity.
we don't have nearly as much control over our health as we do our driving record, and our ability to get a loan.
In a way we do, despite chance or luck or whatever descriptor you choose.
MOST of our health problems can be traced to lifestyle. Too much of this (food or alcohol), too little of that (exercise or proper diet). Still, there are people who, through no fault of their own, find themselves in a medical crisis. Had Christopher Reeve opted not to ride horses, he would perhaps still be flying across the big screen. That was a choice that came with some risk albeit rather small. Many people with that kind of fall do not live. Of course there was the additional tragedy of Dana Reeve contracting and dying of lung cancer even though she never smoked.
Both of these are unfortunate and can be chalked up to chance.
Still, the vast majority of health issues are preventable.
Drunk or reckless drivers make a conscious choice every time they get behind the wheel and it usually impacts others more than themselves.
Many who file bankruptcy or have other credit issues do so because of poor planning. Either they cannot control their spending, or they fail to have adequate safeguards in the event of job loss, death, divorce or unanticipated medical bills.
So those with poor driving records, poor financial records, or poor health do find it is within their control the majority of the time.
And frankly I don't care what other nations do about health care since I don't live there. As has been pointed out many times in this forum, they also ration care and have failed miserably in controlling the costs of health care. All the socialized systems discriminate against the poor and sick equally, which makes them different but not better.
Well Bob, I was going to let you have the last word, but I can't help myself.
.. the vast majority of health issues are preventable.
The vast majority? Could you define vast?
In actuality many of our health problems, or lack there of, can be attributed to our genes. The luck of the draw in other words. Cancer and heart disease, being two diseases that have a very strong familial correlation.
Then there are the conditions of our environment, i.e. where we live, have a strong impact on our health. But I guess you might include that under lifestyle choices?
We can't all live in the unpolluted vast wilderness. It wouldn't be unpolluted, for long, if we did.
As far as all the other countries in the world controlling their health care costs, you're right, they are having the same problems the US is.
But that is because populations all over the world are increasing, and we are living longer, placing greater demands on the health care systems of all countries.
The other countries are just a little more compassionate when it comes to dealing with sickness, and the effects it can have on the lives of many people.
There are no easy solutions. There are solutions, but they are not all pleasant ones.
Rationing is one such unpleasant solution, but in the end, it "may" be the best solution.
other countries are just a little more compassionate when it comes to dealing with sickness
Oh really?
I beg to differ:
Here and here.
(BTW, I doubt that either of you will have "the last word:" this thread is up to 32 comments, with no signs of slowing down. Not that I'm complaining)
See, now that is another complaint of mine.
Whenever anyone wants to throw a monkey wrench into the idea of universal health care (UHC), they always find something wrong with the models represented in Canada or the UK.
I know many UHC proponents use the Canadian model as an example for a US model, but I also recognize the systems in Canada and the UK are failed systems.
There are much better models, in other OECD countries, many very similar to what is already in existance in the US. The prinicple difference being, all those other countries mandate the purchase of health insurance.
So show me an example from another OECD country other then the UK or Canada, i.e. France, Japan, Switzerland, the Netherlands etc.
My real intent of the statement about compassion was referring to the likelihood that in this country that the possibility you can be forced into bankrupty if you get sick is much greater in the US than in other countries.
Still all that being said, as health care costs increase and it begins to consume more and more of governmental budgets, rationing can be expected to be a necessary alternative.
Gee, Marc, you're pretty hard to please:
■ You don't like Bob's analogies.
■ You reject John F's metaphors.
■ You don't care for my factual examples.
■ You (apparently) haven't read the OECD links at the other thread.
You want us to just cry "Uncle!" and shut up?
I didn't think so.
Decaf?
(BTW, we cite Canada and England because they are culturally similar to us. European and Asian countries are not)
I could never understand, everytime you bring up a national health plan, Canada, England and every other country is bought up as proof that it would not work. Where's is the proof. We are the United States of America, the greatest country in the world and the concensus is we can not do something better than Canada. I myself beg to differ. Could it be that the insurance companies do not want it!
Damn! I have to get a life.
France and Italy are culturally different than us? I'm not so sure I would agree with that statement. What about Ireland, Australia, New Zealand? Are they culturally different also?
I have seen those reports before but they don't address the comment I was responding to about how compassionate the system in the UK is.
And to John (in reference to your last post on the other thread), I have repeatedly stated that all countries are seeing a population increase, and an aging of the population, and those are the principle reasons health care costs are increasing all over the world, not just in the US.
But neither does that address the health care crisis facing the US, that is health care linked to employment, leaving many without insurance and access to quality health care, because they have either been layed off or their employer no longer offers coverage due to the cost, and a crumbling health care infrastructure brought about by an unfunded mandate for health care providers to provide universal health care to the citizens of the US.
in this country that the possibility you can be forced into bankrupty if you get sick
And in other countries you can be forced into the grave much sooner and suffer more in the interim while waiting for care.
Bankruptcy or suffering and needless death.
Tough choice.
Of course the alternative to bankruptcy is to . . . plan ahead . . . and have coverage before you get sick or have a serious accident.
France and Italy are culturally different than us?
Yes, unequivocally.
What about Ireland, Australia, New Zealand?
What about 'em? They are neither European nor Asian.
the health care crisis facing the US...linked to employment
Nice strawman, Marc! I reject your assertion that there is any "health care crisis" (except in the minds of the "breathless media" - Thanx, John!). But even if there were, how could it be the fault of employment-related insurance?
Simple answer: it can't.
Marc, in the post you refer to, I was not talking about why health care costs are rising. Instead, I asked why per capita health care costs of many OECD countries have grown FASTER than in the US over the past 15 years?
Per capita costs don't increase because the population increases.
More rapid aging of their populations may be a factor, but the data show only the projected aging from 2000-2050 - whereas the OECD per capita costs have been rising faster than ours throughout the decade of the 1990's up to now.
Will adopting an OECD health system model accelerate US health care spending - per capita - or not? I think it is important to know the answer to this question.
There is no crisis.
No one in this country who wants health care is denied it.
Ever.
Many -- perhaps most -- of those who are uninsured are so because they choose to be.
Those that cannot afford insurance have access, if they choose, to any number of government-run health insurance programs (e.g. Medicaid).
There's your answer.
What about Ireland, Australia, New Zealand?
What about 'em? They are neither European nor Asian.
Ireland isn't a European country? Where is it then?
More rapid aging of their populations may be a factor, but the data show only the projected aging from 2000-2050 - whereas the OECD per capita costs have been rising faster than ours throughout the decade of the 1990's up to now.
More rapid aging may be a factor? And are you saying that in the 90's OECD populations weren't aging faster?
The population in the US has increased 50% in the last 40 years. Now I don't have any stats to back me up, but I'll bet the population increases in the other OECD countries don't come close to that increase.
Maybe that is a good argument for more immigration, legal and illegal.
The real question isn't how much per capita spending is increasing, but what % of the budget and GDP is being consumed by health care spending
Based on what I read, it looks like as a % of GDP, health care costs are projected to be about 2.8% of GDP in 2050, so now the only question is how will the cost be spread throughout the population
some who are denied health care for the lack of funds
Can you provide examples?
In over 30 years in this business, I cannot think of a single person who was denied needed health care due to lack of funds.
Anon:
Ireland isn't a European country? Where is it then?
There's this cool new thing called a map. It shows where countries are in relation to others. Pretty nifty new tech.
Unless there's some kind of undocumented bug in mine, it shows Ireland as part of some obscure place called Great Britain, wherever that is.
Now I don't have any stats to back me up
Well, please let us know when you do. Perhaps that will add context (and credibility) to your comments.
There are many troubling things about this survey. In addition to the puzzling disconnects mentioned by others, patient satisfaction ratings should be interpreted with extreme caution. Consider the following:
1. Despite what the survey says, there is is an undeniable healthcare crisis in our country and a serious knowledge void.
2. Just because patients believe they have received good care, it doesn’t necessarily mean the care they received is adequate. Patient satisfaction is not a valid measure of clinical effectiveness.
3. As one knowledgeable physician put it: “People don't know what good healthcare is because they don't know how bad healthcare is. People don't know how bad healthcare is because they don't realize how good it could be.” -- Dr. Rob Lamberts. So, the more informed someone is about our healthcare crisis, the less likely they will report being satisfied. My guess is that many of the people surveyed weren’t very informed.
Sorry, Steve, but I'll reiterate:
By any reasonable definition, there is no health care crisis in this country.
Dr Lamberts' tautology notwithstanding.
Appreciate your comments, though.
Unless there's some kind of undocumented bug in mine, it shows Ireland as part of some obscure place called Great Britain, wherever that is.
Well, considering there are only 6 continents, Africa, Asia, Australia, Europe, North American & South America, where would you put Ireland?
Or is there a 7th continent I am not familiar with?
And if they're not a European country, how come the use the Euro for currency?
You are certainly entitled to your opinion, HG, but refuting the facts contained in the hyperlinks in my previous post would offer much more credence to your opinion than commenting on Dr. Lamberts quote (who happens to be a very knowledge and compassionate professional). As far as I can tell, you’re basing your opinion on a satisfaction survey of people who have arguably little knowledge of our healthcare system, who lack the knowledge to judge the quality of clinical outcomes validly, and who are likely relatively healthy and economically stable. If even one of these three things is true, it disputes the validity of survey.
If you cannot (or will not) address the information in my previous post, then I can agree with your opinion in only one context: There is no healthcare crisis in the minds of people who are young, healthy or wealthy; people who are ignorant of the facts; and people who gain financially from the current system and believe a change in the status quo will adversely affect their pocket books. power, or status.
In the opinion of the same doc I referred to on another post who broke the healthcare system down into three segments, most people judge the quality of their doctor on what she called the three A's -- affability, availability, and last and LEAST, ability.
Any survey results or analysis regarding the healthcare system using judgments of people with this underlying mentality are of questionable value at best.
Marc:
East Timor uses the US dollar as currency. Does that make it the 51st state?
My point about Ireland being part of Great Britain was to underscore why it's useful to use the English (and Canadian) health care systems for comparison: "they are culturally similar to us." I don't think that anyone would argue that Ireland is culturally different from England.
Steve:
I think that reasonable people can disagree about how to interpret survey results. Likewise, I don't think any reasonable person would argue that USA Today or the Kaiser Foundation are bastions of conservative thought. If anything, they lean more left, and thus are more likely to skew results towards the merits of a nationalized system. That the results appear as they did must have been surprising to them.
I think it's arrogant to believe that even a "knowledgeable and compassionate phsician" like Dr Rob (Aside: I happen to agree with your assessment of him, BTW) knows more about any given person's health and health care than that person.
Likewise, it's always struck me as arrogant when any policy wonk (myself included, I suppose) purports to know what's best for a population as a whole.
Well, please let us know when you do [have stats]. Perhaps that will add context (and credibility) to your comments.
OK, here goes!
France - 42% increase in 50 years
Germany population is actually declining.
Italy - 23% increase in 50 years
I found these interesting facts about the world population, but couldn't give you the link because your site limits the number of links.
During 2005-2050, eight countries are expected to account for half of the world’s projected population increase: India, Pakistan, Nigeria, Democratic Republic of the Congo, Bangladesh, Uganda, United States of America, Ethiopia, and China, listed according to the size of their contribution to population growth.
-- The population of 51 countries or areas, including Germany, Italy, Japan and most of the successor States of the former Soviet Union, is expected to be lower in 2050 than in 2005
Notice the US lumped together with all those 3rd world countries. I hope that isn't an indication of what we can expect the US to become.
Thanx!
because your site limits the number of links
I didn't know that. There are a number of things about HaloScan that I'm just now discovering. I originally installed it to better manage comments and trackback, and it does help with that. But I didn't know that it limited links.
Did you happen to catch how many it allows, and/or is that per comment, or comment thread, or commenter?
TIA!
(BTW, I hadn't realized that you were the "anonymous" poster. I just presumed it was one of those "drive-by" trolls; I don't have much patience for those. Just went back and compared IP's, and saw that it was, indeed, you; fixed now)
Just because patients believe they have received good care, it doesn’t necessarily mean the care they received is adequate.
You are kidding, right? That has got to be one of the all time classic excuses I have heard on the so-called crisis.
I can accept that premise for someone who is mentally ill or incompetent, but I refuse to believe it is a valid argument for indicting health care as a whole.
And this aside . . . if the survey, remember the survey from the original post(?), is about US health care why have the comments gone off track into discussing population growth in other countries?
Seems if you were truly concerned about the validity (or fallacy) of the survey you would seek to discredit the conclusions rather than making ludicrous statements claiming that patients really don't know how bad their health care is because they are ignorant & uninformed.
remember the survey from the original post(?)
There was an original post?
Yeah, we did get side-tracked. Good point.
Did you happen to catch how many it allows, and/or is that per comment, or comment thread, or commenter?
I only had to delete one, so can only assume 3 is the limit.
(BTW, I hadn't realized that you were the "anonymous" poster. I just presumed it was one of those "drive-by" trolls; I don't have much patience for those. Just went back and compared IP's, and saw that it was, indeed, you; fixed now)
I was the anonymous poster? Are you sure? If I was it was an accident, since my name etc. just comes up automatically.
Very puzzled. Which post was it?
3 is the limit
Was unaware of that. I'll see if that's something I can adjust; I can imagine times where folks would have more than 3 links to cite, and don't want to bother with multiple posts.
Which post was it?
IIRC, this one (but I fixed it, based on the IP).
HG wrote: “USA Today or the Kaiser Foundation … are more likely to skew results towards the merits of a nationalized system. That the results appear as they did must have been surprising to them.”
Maybe so, but that doesn’t mean it’s reasonable to interpret the results of any one survey as negating tons of data pointing to exact opposite conclusion: American healthcare is in crisis, as least in the eyes of folks aware of the quality and cost problems, which, btw, you don’t refute. All you’re saying is that a group of people surveyed say our healthcare system is basically OK in their eyes (although many agree it’s too expensive). Administer the same survey to the tens of millions who cannot afford insurance, to the families and friends of the 100,000 patients a year who die from medical errors and many more who are harmed, to healthcare professionals who have spent years studying the problems, etc. and you will get much different results. On the other hand, administer the same survey to people with stable jobs whose insurance is paid by their employer, who are young and healthy, and who are ignorant about the serious underlying problems plaguing our system, and you will get even greater satisfaction ratings. So, is there a healthcare crisis: It depends who you ask and how much they know and are aware.
HG wrote: “I think it's arrogant to believe that even a ‘knowledgeable and compassionate phsician’ … knows more about any given person's health and health care than that person.”
I don’t know who said that. Personalized care, which I suggest should be a part of a transformed healthcare system, takes into account patients’ insights, preference, complaints, and feelings of satisfaction. It involves a patient-provider team-like approach. As a matter of fact, I’m a proponent of collecting directly from patients comprehensive information about the symptoms/problems they experience, and encouraging patients to learns as much as they can about their conditions, and having their providers help answer their questions and concerns. So, while providers have training, experience, and technical expertise patients lack, I agree that a patients’ perspective about their problems should a crucial part of the decision-making process.
BUT, even though a patient feels better after treatment, it’s very unlikely s/he would know if it is the best possible care delivered in the most cost-effective manner, or if it is merely adequate delivered inefficiently, or if it is poor care that will lead to worse problems not yet noticed by the patient. Conversely, if a patient feels lousy and financially bankrupt after treatment, it doesn’t mean that the care received is inferior quality or excessively costly; it might be the best, most affordable care that could be done considering circumstances. In other words, while patient input is absolutely vital to quality care delivery and no decisions should be made without it, validly judging the effectiveness and efficiency of any healthcare regimen is a complex issue that no patient survey can adequately address.
HG wrote: “Likewise, it's always struck me as arrogant when any policy wonk (myself included, I suppose) purports to know what's best for a population as a whole.”
It’s not arrogant to claim knowledge of a wise path to a better healthcare system, as long as it is open to scrutiny, accommodates valid criticism, and considers alternative solutions. This is the approach we take with our evolving solution presented on our Wellness Wiki; we invite criticism so we can continually improve it.
Nevertheless, what’s even more interesting about your statements is the phrase “population as a whole.” If we focus only on a subset of the U.S. population, i.e., the young, healthy, wealthy, and uninformed, then it is possible to make a case that our current healthcare is acceptable from their point of view. But if we consider the needs of the entire population, which includes those who actually consume a large percentage of healthcare resources, struggle to pay for it, and suffer from its quality problems, it’s very doubtful they will claim things are OK! Maybe this simply reflects the growing divides in our country, with some benefiting greatly from the status quo, and many experiencing great distress.
When I wrote: “Just because patients believe they have received good care, it doesn’t necessarily mean the care they received is adequate.” Bob replied: “You are kidding, right? That has got to be one of the all time classic excuses I have heard on the so-called crisis. I can accept that premise for someone who is mentally ill or incompetent, but I refuse to believe it is a valid argument for indicting health care as a whole.”
First, Bob, this is not any excuse about anything; it simply states that in many situations patients lack the technical understanding to know if the care they received is as good as it could be. For example, there are things like the placebo effect, where the treatments themselves did nothing, but simply having a doctor pay attention to the patient makes the patient feel better.
But even more importantly, consider the “practice variation” problem in which different providers treat similar patients in vastly different ways for significantly different costs, yet cost is unrelated to the quality of care delivered. With this in mind, maybe we’re having a problem with semantics: I consider safe, quality care delivered efficiently (i.e., cost-effectively) to be “adequate,” while unnecessary or overly-expensive care resulting in similar outcomes to be “inadequate.”
So, let me chose a better word, “value,” i.e., high value care is safe, effective and efficient: Quality divided by Cost. Then to rephrase my statement: “Just because patients believe they have received HIGH-VALUE care, it doesn’t necessarily mean the care they received is HIGH-VALUE.” Do you have a problem with this? If so, why?
Bob wrote: “And this aside . . . if the survey, remember the survey from the original post(?), is about US health care why have the comments gone off track into discussing population growth in other countries?”
My comments are about American healthcare.
Bob wrote: “Seems if you were truly concerned about the validity (or fallacy) of the survey you would seek to discredit the conclusions rather than making ludicrous statements claiming that patients really don't know how bad their health care is because they are ignorant & uninformed.”
Validity means that the data support the conclusions drawn by the analysis and interpretation of the data. Consider the following:
I suggest a valid interpretation of the survey would be healthcare in the U.S. is fine IF the survey results were based on the knowledgeable experiences and insights of people who understand the important economic and clinical issues involved.
Another valid interpretation of the survey would be the people surveyed who believe healthcare in the U.S. is fine are those who … and then list the characteristics of such people in terms of their degree of knowledge, experiences and insights about the important economic and clinical issues involved, as well as their economic status, health status, dealings with health plans, etc.
And if the survey results were presented as correlations between people’s level of satisfaction and their employment status (e.g., do they receive insurance through their work), income level, health status (how sick are they), degree of healthcare system knowledge, etc. – rather than overall percentages that hide all these details – the survey would be much more meaningful and less prone to questionable interpretations.
in many situations patients lack the technical understanding to know if the care they received is as good as it could be.
You have a right to believe what you will, no matter how foolish it makes you appear.
Bob (and Steve)
I thought Steve's comments were very thorough, comprehensive and sensible. Foolish would be one of the last words I would use to describe them.
Let's take a concrete example regarding the recent publicity about a large group of interventional cardiologists in Elyria, Ohio. The New York Times reported that this group was implanting stents in Medicare patients at over 4 times the national average rate. They previously had a reputation for providing good care and the local hospital was, in fact, one of United Healthcare's Centers of Excellence. However, it turned out that many of these patients could have been treated much more cost-effectively with drug therapy while some of the sicker patients probably should have gotten bypass surgery (CABG). However, these doctors make their living inserting stents, not doing bypass surgery or putting people on drug regimens. In short, they were acting primarily in their own financial interest and not their patients' best interest. Was this good care? Was it cost-effective for Medicare and other payers? My answer to both questions is NO! I have no idea, of course, how the patients themselves would answer the same questions either before or after they knew what they know now.
Steve, you seem to be taking the position that only people who are themselves health care professionals (or who have specialized knowledge of health care) are entitled to have an opinion that counts on this issue.
If I'm not getting you, please clarify.
Thanks -
I know for a fact that people have no idea whether the care they received was any good or even necessary.
When I was first diagnosed, I consulted with a doctor at MD Anderson, THE MOST RESPECTED CANCER HOSPITAL IN THE US (not in the world).
I was told in no uncertain terms that I should immediately begin treatment, chemo plus a transplant. But I said I feel fine, and none of my markers indicate that to be the case.
That didn't matter. Since I had MCL, I needed treatment.
And you know what, 4.5 years ago I could have taken that advice and had that treatment they recommended. After all they are THE MOST RESPECTED CANCER HOSPITAL IN THE US . But I chose not to and got more advice from people who were even more knowledgeable, at least IMO, outside the US.
So in retrospect should I have had the treatment? Where would I be today if I had?
There is no doubt that I would have had a remission, but now I would probably be out of remission (a typical remission lasts on average 5 years, and there is no cure for NHL) and needing additional treatment, because when your lymphoma returns, it always returns more potent than before.
In the process I would have gone through pure hell with the chemo. I'm not sure how many of you know, chemo really isn't medicine. Most knowledgeable people liken it to blood letting in the dark ages, and the side effects and long term effects can in many cases be worse then the disease itself.
If I was unknowledgeable, I would have thought I received the greatest care in the world, when in fact it would have been the worst thing, and I certainly wouldn't be any better off, or felt any better than I do right now.
And there are many people who are unknowledgeable. I had many people tell me at the time, if MD Anderson recommends treatment, then you should take it. After all they are THE MOST RESPECTED CANCER HOSPITAL IN THE US (just not the world). I've often wondered about the motives of MD Anderson, since they will typically prescribe treatment, when others don't, as there is no money to be made by NOT providing treatment.
And there are still people on the various email groups that I belong to that just go for treatment without regard for second opinions, or knowing if the care they are receiving is the best possible. (Read this recent post on my personal blog - Opinions and the practice of medicine.)
I have a friend who can't understand when I question my doctor, and claim to know more than them. He believes what ever his doctor tells him. I try to tell him otherwise, but he doesn't listen.
I even have two other friends who have non hodgkins lymphoma (NHL), but when I ask them what kind of NHL they have, they just tell me NHL. They don't know. They don't know there are many different variants of NHL, and even different variants within the variants, all requiring different approaches to treatment.
Why don't they know?
They don't know, because they are not knowledgeable. They think doctors know everything, and no doubt think they are receiving great care.
And they may be receiving the best and most appropriate care, but it might not be the best care. They are just not knowledgeable.
And those are the sick people. How many of the healthy people think they are receiving the best care, and don't know it?
So there!
>Of course the alternative to bankruptcy is to . . . plan ahead . . . and have coverage before you get sick or have a serious accident.
In an employement based system, having had previously obtained insurance does you little good in the event that you become ill and lose your job.
In an employement based system, having had previously obtained insurance does you little good in the event that you become ill and lose your job.
COBRA gives you a minimum of 18 months coverage, then 36 states have a risk pool. Other states have other HIPAA compliant policies that can be picked up after COBRA.
I don't know of a single state where, once COBRA expires, you have no options.
Most (if not all) states have COBRA type laws that impact employer plans with less than 20 employees. So even if you work for a smaller company, you still have options.
Marc -
I can cite examples where folks survived car crashes with fewer injuries despite the fact they were not wearing a seat belt. Does this mean you should not wear a seat belt?
Sure, but only if you have the ability and knowledge of what will happen to you and when.
Just because you feel you did not receive the best care, does not in and of itself become a wholesale indictment of the system.
Right now approximately 83% of the population have health insurance and 100% have access to health care regardless of their ability to pay. Approximately 95% of the population that wants to work has a job. About the same number have a roof over their heads.
But we also have a system where the top 50% of income earners shoulder 93% of the tax burden.
The only real crisis is the tax system. Something is terribly wrong there.
Bob, I was merely responding to your statement
You have a right to believe what you will, no matter how foolish it makes you appear.
It's not a foolish statement. It's a very true statement. In most cases, people lack the knowledge to know if they have received the best care, or even adequate care.
And again I'll ask, what does the wearing of seat belts have to do with receiving adequate health care?
Steve:
interpret the results of any one survey as negating tons of data
Never said it did. Since the post reported on one specific study, I focused on that. I don't disagree, BTW, that it is not authoritative; it is what it is. But it's interesting (at least to me) that the so-called "crisis" is largely the creation of "the breathless MSM" [(c)J Fembup, 2006].
I don’t know who said that
That would be: "People don't know what good healthcare is because they don't know how bad healthcare is. People don't know how bad healthcare is because they don't realize how good it could be.” -- Dr. Rob Lamberts
It’s not arrogant to claim knowledge
No, it's not. It is arrogant to frame one's argument around the premise that "even though a patient feels better after treatment, it’s very unlikely s/he would know if it is the best possible care."
By way of example:
I know enough about my car to be able to fill it up, wash the windshield, and change the wiper blades. I trust my mechanic to handle more complex issues (brakes, tune-ups, etc). Do I know for a fact that he's giving my car the best possible service? Of course not. But at some point, I have to trust him enough to leave my safety (heck, my family's safety) in his hands.
I immediately stipulate that the "health" of my car pales in comparison to the health of my body. But it seems to me that it adequately demonstrates that the issue of trust, as well as outcomes, is relevant to the discussion at hand.
In fact, your comments really underscore for me the importance and value of one of my own pet issues: transparency. You argue that we as consumers are poor judges of the quality of the care we receive. Would you then argue, as well, that by seeking out relevant information about costs, outcomes and alternatives that we're essentially spinning our own wheels?
BTW, regarding your previous assertion that I hadn't "refut(ed) the facts contained in the hyperlinks in (your) previous post:" I didn't do so because this discussion is about the Bob's post, and the survey that he cited. That is not to say that they're not important, or relevant; but at some point, the discussion must focus on the information at hand. Obviously, you're free to disagree (as I'm somehow sure you will ), but that's the way I see it.
Finally, I really owe Bob a big Thank You for this post: this comments thread is quite interesting, and I appreciate the various points of view being espoused here, even if I don't agree with some (maybe because I disagree with them).
Programming Note: Sorry for the delay in comments approval. The nice thing about using HaloScan for comments management is that it allows for control over trolls (obviously, that doesn't apply in this thread); the downside is that it's dependent on the "Siteowner" to periodically "approve" the backlog.
I try to keep up with them, but the combination of:
a) the incredible response to this post (Thank you, everyone!) and
b) some personal issues today
have left me lagging behind. The management appreciates your patience
Let me start by saying this is a very good discussion dealing with difficult concepts and issues. I appreciate HG’s willingness to approve controversial comment and everyone’s willingness to engage in “deep dialogue” by sharing their thoughts and feelings and continuing to hammer away at this problem with open, critical minds in search of deeper understanding. Our country needs more of this kind of debate!
If I now may attempt a brief summary of the last round of posts:
Bob responded to my comment: “in many situations patients lack the technical understanding to know if the care they received is as good as it could be.”
with his comment: “You have a right to believe what you will, no matter how foolish it makes you appear.”
BC replied: “I thought Steve's comments were very thorough, comprehensive and sensible. Foolish would be one of the last words I would use to describe them” and then proceeded to give an example of how difficult it is for a patient to determine the value of a stent implantation process for CABG.
Marc supported BC with his real-life experience of how even very intelligent patients struggle to understand technical issues about treatment of their illnesses (MCL and NHL).
John then questioned if I'm “taking the position that only people who are themselves health care professionals (or who have specialized knowledge of health care) are entitled to have an opinion that counts on this issue”
Jaye mentioned the vulnerability of an employer-based insurance system.
Bob asserted that the vast majority of people in our country have health insurance and everyone has access to healthcare. He sees the primary underlying problem to be a tax burden on the wealthy.
HG suggests that J Fembup is correct in asserting the mainstream media (I assume that’s what MSM means) is responsible for the so-called healthcare "crisis."
He then states the opinion that it is “arrogant to frame one's argument around the premise that ‘even though a patient feels better after treatment, it’s very unlikely s/he would know if it is the best possible care’ and gives an example of the need to trust a mechanic with one’s car, just like we should be able to trust a doctor with our healthcare. He also states that transparency and outcomes research is critical.
OK. It seems to me that we are coming to the consensus that few patients for which there are alternative treatment to their medical problems have the knowledge to determine what treatment approach is the safest, highest quality, most affordable, i.e., what is likely to result in the greatest benefit, with least risk, for least cost, as well as which providers are likely to deliver that care in the most effective and efficient manner as evidenced by valid clinical and financial outcomes data. This is difficult to refute since healthcare professionals often don’t even have much of clue -- I again refer to the Knowledge Void , as well as BC’s and Marc’s posts.
In response to John’s question about giving people lacking healthcare knowledge a meaningful voice, I say this: We ought to be doing much more research focused on comparing different approaches to the same health problem/condition in order to define with clarity the particular treatments showing to be the safest, highest-quality, and most cost-effective care for every type of patient. While this is a very challenging task for many reasons and will require considerable time and resources, the benefit would be empowering patients/consumers with knowledge needed to make informed decisions. Transparency and outcomes research, to which HG referred, are crucial to accomplishing this. Unfortunately, such efforts are only in their infancy due to decades of resistance and foot-dragging.
In the mean time, patients/consumers certainly have the right to express their opinions, share their experiences, and offer their insights, like is being done on this blog. In fact, I believe the greatest power-drivers of change will be the public: What we need is a grassroots movement to educate and motivate the public to demand transformation of our healthcare system. My only issue in this discussion thread has to do with the interpretation of the Kaiser study.
As to Bob’s assertion that things are OK because most people have health insurance, 45 million lacking insurance is a serious problem in my eyes, and considering Jaye’s comments, no wise employee will be lulled into a false sense of security about their employer-paid coverage (and as I understand it, COBRA is expensive, especially for someone out of work). Yes, there are alternatives to employer-based insurance, including Welfare if you qualify (and want it) and self-insurance if you can afford the astronomical costs (e.g., nearly $12K/year for a family in NY). And no insurance is also an option: Just go the emergency room if you get sick and sit for hours in an overcrowded waiting room with others in your position thereby perpetuating the problem, and let the tax payer pick up the bill after you go into bankruptcy, or let the hospital eat it. Not great options in my eyes.
As per Bob’s view that the primary underlying problem is the tax burden on the wealthy, all I can say is that our system of taxation is one of many problems with the American economic system, which puts the top priority on shareholder equity and corporate profits. Added to the other things we’re discussing, it points to the need for transformation of many of our economic-political-social systems. May I recommend a very enlightening book: Frances Moore Lappe’s “Democracy’s Edge.”
45 million lacking insurance is a serious problem
40% qualify for taxpayer funded plans such as Medicaid, yet fail to apply for coverage.
20% earn too much to qualify for taxpayer plans and are just barely living paycheck to paycheck.
40% earn in xs of $50k and can well afford health insurance, they simply refuse to make the purchase.
100% of those without health insurance or the ability to pay are not denied needed health care.
There is no crisis except in the minds of the uninformed.
Steve, a very useful summary, I even read it a second time.
Couple of quibbles -
1. I differ with your statement that "HG suggests that J Fembup is correct in asserting the mainstream media (I assume that’s what MSM means) is responsible for the so-called healthcare "crisis." That's not what I said, and it's not what the Prof agreed with. I said it's my opinion that the MSM's continual misreporting of health care issues explains the many "disconnects" found in the abc/KFF./USAToday survey. I did not say, or imply, that there are no problems in our present system - in fact I explicitly stated the reverse.
2. This blog is for insurance not tax, but tax policy does have a bearing on how insurance is financed. For my 2 cents on this matter I think the issue of "corporate taxation" is a red herring. Corporations do not pay taxes - they only collect them. You and I and everyone who produces anything of value in our economy pay the taxes. Current tax policy does distort the insurance markets. For that reason I favor - in theory, anyway - eliminating all corporate taxes, rather than further complicating the tax code with e.g., an insurance tax cap.
Again thanks for the useful summary. I agree that discussion is important. From the other board, you know I believe that as a nation, we are nowhere near a consensus about what to do with our current set of problems. Everyone has their own perspective, agenda, facts, biases, solutions, arguments, and egos. About all we do agree on is that we don't like what our nation has (and, oddly enough according to the survey, most of us DO like what our own family has).
I even read it a second time.
Just fixed that. Been out of town all day, just got back.
Thanx, Bob, for holding down the fort!
And I agree with John: That was a very useful summary; Thanx, Steve!
Of the 45 million lacking health insurance, Bob makes the following claims. Assuming these statistics are valid – and, Bob, I would appreciate the reference to your sources – then here are my thoughts:
“40% qualify for taxpayer funded plans such as Medicaid, yet fail to apply for coverage”
> So why don’t these 18M simply get the coverage? Since I’m not an insurance specialist, I lack the knowledge I need to answer such a question. I assume you’re saying that these folks know about Medicaid, it’s relatively easy for them to get, and that it is a good healthcare plan with similar coverage, benefits and access to providers as most health plans.
Consider this: Data from the Community Tracking Study provide a valuable perspective from which to observe how economic disparities--largely a function of different sources of coverage--influence access to medical care in the United States. Many recent investments and initiatives are focused on affluent communities and are accessible mainly to people with employer-based or Medicare coverage. For people with Medicaid or no coverage at all, access to basic care is worsening, as a result of stalled coverage expansions and service cutbacks (Reference)
“20% earn too much to qualify for taxpayer plans and are just barely living paycheck to paycheck.”
> Well, these 9M are just plain out of luck. The working poor, I assume. Some would probably say they are part of the new middle class.
40% earn in xs of $50k and can well afford health insurance, they simply refuse to make the purchase.
> So, if I’m one of these 19M, am the head of a household, and a family plan costs me $11K/year, I assume you’re saying I shouldn’t have too much difficulty living on $40K minus taxes after paying my premiums. Or I can reduce my premiums with an HSA/HDHP, pay, say $7K/year and hope that my deductibles and co-pays don’t send me into bankruptcy. Again, not being an expert in this area, I wonder what it would take for such a person to be persuaded to purchase coverage. Might it be that paying nearly 20% of you income on health insurance that increases every year is just too steep for some people?
“100% of those without health insurance or the ability to pay are not denied needed health care.”
> True. Just go to the ER. Unfortunately, that’s big a problem in itself. For example, being treated in an emergency room for something a primary care physician can treat increases overall healthcare costs and slows an ER’s ability to respond to emergencies.
Regardless, the issue for me goes well beyond the problems, costs, and inequities of insurance. The need to improve care safety, quality, efficiency, and accessibility for everyone is of the utmost importance for me, and is what constitutes our healthcare crisis. It’s a weak argument to state that everything’s fine the way it is just because a portion of the uninsured chose not to buy insurance, people making over $50K should be willing to spend up to 20% of their income on insurance, and anyone can get treated in the ER; that just doesn’t cut it for me.
Thanks for the clarification, John. Deep dialogue like we're having here is, I believe, a step toward greater understanding and increased consensus. And I agree it ain't easy!
I'm glad the summary is useful, HG.
The numbers vary slightly from study to study almost always break out around the same 40/20/40 split.
http://insureblog.blogspot.com/2...-
revisited.html
http://insureblog.blogspot.com/2...ising-
tide.html
http://insureblog.blogspot.com/2...ealth-
care.html
So why don’t these 18M simply get the coverage?
Ignorant? Pride? Uninformed? Take your pick.
these 9M are just plain out of luck. The working poor, I assume. Some would probably say they are part of the new middle class
Not out of luck. They can still get health care when they need it.
They are not paying any taxes to speak of, so we still support them with our tax & insurance dollars.
paying nearly 20% of you income on health insurance that increases every year is just too steep for some people?
Those are your figures,not mine.
A family of 4 in Atlanta (not a low cost area) in their mid 30's can get all the coverage they need for less than $300 per month.
Make them 10 years older and they can still get coverage for under $400 per month.
Move them in to their 50's and drop the kids off and the premium is still under $500 per month.
Thanks for the numbers, Bob.
In contrast, a family of 3 in NY with a traditional health plan from BSBC cost $954/mo. The premiums are much higher, as I understand, since this is a "community rated" state (as are several others), which means everyone gets the same rate regardless of their health. In other states, the premium rates depend on one's health. So, there seems to be a dizzying array of prices and coverages, as well as tactics (such as re-underwriting).
Just because some segments of our population can received affordable (and even no-direct-cost employer-paid) insurance, and just because some members of our population are satisfied with the health care they’ve received (or assume they would get great care they can afford if they ever needed it) -- it is not wise, imo, to conclude that all is well with our healthcare system.
The bottom line is that the preponderance data shows our system is in crisis and the survey we’ve been reviewing does nothing to refute this fact. While the current system works for some people and fails for others, it remains clear that there’s urgent need to transform the system so everyone receives safer, higher quality, more efficient, more affordable care.
"the bottom line is that the preponderance data shows our system is in crisis and the survey we’ve been reviewing does nothing to refute this fact"
Steve, I hate to disageee, but . . .I disagree.
It seems to me a contradiction in terms to look at the survey and conclude - after long and involved discussion in which there are at least as many opinions as participants - that by some "preponderance" there is a "crisis". Bob Dylan said “you don’t need a weatherman to know which way the wind blows” Good thinking. IMO, this survey does not reveal the existence of a health care crisis.
So what does it reveal? IMO, its main finding is to confirm an already-established problem shared by about 15% of our population. That problem is no insurance. This 15% has no insurance either because they cannot afford it, cannot get it, don't know how to get it, or choose not to get it.
IMO, that problem is misrepresented by the media and others who erroneously equate “no insurance” with “no health care” – when in fact this uninsured 15% of the population does have access to emergency health care. So more specifically the problem is how can the 15% without insurance secure access to more comprehensive health care? I believe it is in the national interest to do so, for many good reasons. But let's be precise. This is a problem in access to health care for a significant minority of people and the problem has emerged because of the high cost of health care. It does not call for a solution that will overturn the system that satisfies 85% of the people in order to improve access for 15%. It does not rise to the level of a "crisis" in health care.
IMO however, we in fact DO have a crisis in health care COSTS. The survey does not say much about that. The responses suggest that the people who can pay, like their situation and the people who cannot pay, don’t. Well, duhh.
IMO, the barrier to access is the cost of health care. If health care were not expensive, health insurance would not be expensive. If the cost of health care were not rising the cost of health insurance would not be rising. A mechanism to make health insurance “affordable” by say, public subsidies, would be an aspirin tablet, not a cure for the disease of high cost. It would provide some symptomatic relief, but without changing the factors responsible for high, and uncontrollably rising health care costs, the costs will continue to rise. IMO, the cost of health care is the true “crisis” because the cost of health care affects everyone not just 15%.
IMO,reducing health care costs will reduce the cost of insurance. But subsidizing insurance without reducing health care costs will only pour more oceans of money into a system that cannot control its costs. That's just not reasonable. We should resist being panicked into such a path by breathless and dire reports of “a crisis in health care” when the crisis in fact is not in the care, but in the cost of the care.
Excellent post, John. To reduce healthcare costs, I think we need to find sensible ways to reduce healthcare UTILIZATION. I can think of several ways that we might attack utilization such as:
1. High deductible health plans coupled with roubust pricing, and, eventually, quality transparency, at least for the services, tests and procedures that most easily lend themselves to pricing transparency.
2. Malpractice litigation reform with the objective of breaking the culture of or at least mitigating defensive medicine. While malpractice insurance premiums and payouts are not a large factor in overall healthcare costs (1% or so), defensive medicine is much more significant but impossible to quantify precisely.
3. A more vigorous effort to crack down on fraud, especially in the Medicare and Mediaid programs would be helpful, in my opinion.
4. A more common sense and realistic approach to end of life care, even without going all the way to QALY metrics. Everything from a much more aggressive effort to get people, especially the elderly, to execute living wills and advance directives to changing the law to allow Medicare to specifically take cost into account in deciding what drugs and treatments to pay for or not pay for to redefining what constitutes sound medical practice.
4. Do as much as possible to utilize generic drugs instead of brands when one is available and just as effective. Getting rid of DTC advertising might also be useful.
In the non-utilization arena, we should look for ways to make the delivery of healthcare more EFFICIENT including much more widespread use of electronic medical records and, perhaps, more consolidation among insurers as well as simplification and streamlining of their offerings.
BC:
I agree with you re: John's assessment. But then again, I'm (almost) always impressed with his stuff.
I'll cherry-pick a bit here: EMR has its own set of problems , as well.
Just FYI.
family of 3 in NY with a traditional health plan from BSBC cost $954/mo. The premiums are much higher, as I understand, since this is a "community rated" state
Therein lies the rub of allowing the govt to interfere with free trade and dictate what a carrier can and cannot do.
bottom line is that the preponderance data shows our system is in crisis and the survey we’ve been reviewing does nothing to refute this fact
Would that be survey's of individuals who really don't know there is a crisis? The same folks who really don't know enough to realize they are getting less than top flight care?
Then obviously the survey system is totally flawed and should be disregarded except by those who are learned enough to comprehend the complexities of the health care system. The people surveyed must be idiots!
Wow … We seem to be coming to some sort of consensus!
John makes good sense by pointing out that insurance premiums would be lower if providers delivered more cost-effective care and payers passed the saving onto the consumer.
BC offers good recommendations for accomplishing this, and HG’s caution about EMRs is valid.
This means the healthcare industry should focus transforming its practices, processes and tools for continuous (a) improvement in care safety and quality (as measured by clinical outcomes, including the rate of errors & omissions, symptom reduction, mortality, complications, quality of life, etc.), and (b) increase in efficiency (as measured by costs, expenditures, resource consumption). It also means that insurers must act with integrity and not just pocket the increased savings, and that providers not try to “game the system.”
I’d like to add another word of caution: As is all too typical in American business, tactics used to increase profits often work against consumers. This includes things like cherry-picking, pricing members out of the market when they need insurance most (re-underwriting), making it virtually impossible for consumers to compare plans in order to find the most suitable ones, denying care for reasons driven by the profit motive rather than patient need, charging small businesses and individuals much higher rates than large companies, delaying payments to providers and instituting claims submission processes designed to cause errors justifying non-payment of the claims, etc. While strategies such as these may make good business sense, they are not good for the country and do contribute to overall healthcare crisis. Not being an insurance expert, I don’t know how prevalent are these practices, but I’ve personally experienced some as a patient and as a provider.
One final point: While we all agree there’s a crisis of healthcare cost, I continue to claim that there’s a corresponding crisis of healthcare quality. That is, the safety and effectiveness of care is in critical need of improvement based on reports of unacceptably high numbers of errors, omissions, hospital-based infections, complications, deaths by treatment (twice the mortality rate of automobile accident deaths), diagnostic and treatment delivery mistakes, as well as the lack of care coordination across providers, the inadequate development and implementation of evolving evidence-based guidelines, the failure to integrate well-care with sick-care and bodily care with psychological care, and inadequate means for protecting populations in emergencies. Even though high-quality care typically reduces costs in the long term (e.g., through prevention, more rapid recovery, and fewer errors, complications and readmissions), care quality problems contribute to the healthcare crisis irrespective of cost. The “practice variation” literature actually shows that quality may be greater in areas where utilization is lower. As such, the best way to describe the situation may be as a crisis of healthcare “value.”
We seem to be coming to some sort of consensus
Perhaps, but I'm not sure what you do with one. On the one hand, IB does enjoy a fairly eclectic readership (based on content and referrals). It's possible that actual policy/decision makers are taking note of this discussion (hey, why not?), but what will their "take-away" ultimately be?
I continue to claim that there’s a corresponding crisis of healthcare quality
Okay, no one's stopping you (and I'm not sure that I disagree). But this is an insurance blog, so I refer you back to my previous point.
quality may be greater in areas where utilization is lower
Now there's a conclusion which I hope is correct (cf: hsa).
FWIW, this thread has generated over 80 comments, easily a new IB record.
And I have a feeling we're not done yet.
“Therein lies the rub of allowing the govt to interfere with free trade and dictate what a carrier can and cannot do.”
Again, it depends. Someone with a serious/chronic illness in states that are not community rated might be re-underwritten right out of the market in order to keep rates lower for the young and healthy. This is directly related to something Marc has posted elsewhere about whether healthcare is a commodity distributed according to the ability to pay or a social service distributed according to medical need. Some might even argue that there’s a serious disconnect between the profit motive and compassion for those in need. This issue goes to the heart of Capitalism in America today, the “fairness” of free trade and whether it is truly “free,” the sense or lack of community spirit, whether we should care about people who don’t take good care of their own health, our sense of responsibility for older and sicker citizens, and other such topics that are probably beyond the focus on this blog.
“Then obviously the survey system is totally flawed and should be disregarded except by those who are learned enough to comprehend the complexities of the health care system. The people surveyed must be idiots!”
No. The survey should be interpreted within certain constraints. That is, it is important to know how the results relate to the demographics, health status, and level of understanding of the people surveyed. For example, it would be good to know what percentage of the people who think everything is great are young and healthy individuals receiving employer-paid insurance, and visa versa. It would also be helpful to know the relationship between the degree of satisfaction and people’s knowledge of the problems existing in healthcare today. In other words, it would be reasonable to interpret the results of the survey to mean that there is no healthcare crisis if the old, infirmed, lower income participants having knowledge of the complexities of the system report that everything is just fine. Otherwise, the only logical interpretation of the survey is that the perception of a healthcare crisis depends who you ask and how you ask it.
It's possible that actual policy/decision makers are taking note of this discussion … but what will their "take-away" ultimately be?
What I’d like them to take away is the recognition that our healthcare system is in dire need of meaningful reform across the board. The most productive transformation would come from a focus on continually improving care quality and efficiency through new policies and practices that support collaborative efforts to: promote ongoing outcomes research, develop and use of evolving evidence-based guidelines shown to increase care value, implement a rational approach to dealing with end of life care, support sick-care with well-care, take a whole-person (mind & body) view of the patient, offer personalized care, coordinate care across the entire healthcare continuum for each episode of care, use IT systems for information sharing and clinical decision support, use the less costly treatments when multiple options are shown to yield similar results, eliminate paperwork that has no impact on care improvement and cost control, develop better systems for biosurveillance and post-market drug and device surveillance, monitor and deal with fraud more effectively, lower insurance premiums when there are savings from reduced utilization while rewarding providers delivering cost-effective care, reform malpractice litigation, and redirect competition so it is based on value. Whew … There’s much that can be done!
quality may be greater in areas where utilization is lower -- Now there's a conclusion which I hope is correct
See, for example, http://www.msnbc.msn.com/id/1517...5/site/
newsweek
But this is an insurance blog
In that case my question would be, was this post about insurance?
Secondly, the concept that "over utilization" of health care is a major contributor to the rise in health care costs, and mentioned by BC as necessary to reduce costs, I would like to know what data there is to support this claim?
I believe this study suggest otherwise, but.........
But the real question then becomes how do you differentiate between necesssary and unnecessary utilization?
I couldn't find anything else which I considered scientifically obtained data.
was this post about insurance
Since insurance covers health care then the answer would be yes.
the concept that "over utilization" of health care is a major contributor to the rise in health care costs, and mentioned by BC as necessary to reduce costs, I would like to know what data there is to support this claim?
Somewhere in the archives of actuaries you will find the data. Or Mr. Fembup might have some supporting documents.
In summary, this is the way the game is played.
Claims drive premiums.
Claims are measured in magnitude (how big the claim is) and utilization (how many claims are filed). If there were no medical inflation, claims AND premiums would still continue to increase unless the population were static or stopped aging and suddenly became healthy (or healthier).
There are a finite number of providers to treat the population. If there is more demand for health care due to aging and/or population growth then simple economics dictate that prices will rise to offset the increased demand. Economists refer to this as inelasticity since there is no substitute for health care.
So utilization increases (due to the aforementioned issues) and health care costs (and premiums) also increase absent medical inflation.
Add medical inflation to the mix and the pricing becomes even more pronounced.
"what will their "take-away" ultimately be? "
I think four things.
(1) That there are too many uninsured people and some basic level of insurance must be implemented for the uninsured. We will describe this to the public as a "temporary" measure so the majority of voters will not go nuts over it, and we will lie about its cost so as to get the measure passed. Then we will hope that it goes away as a political issue until after we retire.
(2) That the principal problem is the cost of health care and we have NO idea what to do about that. Few of us agree on anything. But even we understand that any action having a prayer of reducing cost must reduce the per capita amount of money flowing into the system and that's messing with doctors' incomes. I will give up my firstborn before I go THERE. Besides, doctors vote, and they talk to their patients who also vote. So this is even worse than messing with teachers or retirees.
(3) We'll form a blue-ribbon commission to report to the President how people can take better care of themselves and then we'll just go on blaming insurance companies: "Here's another nice mess you've got us into." The public likes it when we blame insurance companies. They think it means this mess is not their fault and fixing it won't cost them anything.
(4) Oh, and whatever we do, we won't remind the public that Medicare has unfunded liabilities estimated to be more than 11 TRILLION dollars and we haven't a clue how to pay for that unless we raise taxes forever.
Thank you, John!
I'm feeling MUCH better now.
I think four things . . .
John, I think I know where I have met you before. You go by a different name, and appear at the end of "60 Minutes" each Sunday. You are Andy Rooney incognito, right?
"So utilization increases (due to the aforementioned issues) and health care costs (and premiums) also increase absent medical inflation."
I knew that. In fact I have been saying that for a long time, health care costs are increasing because demand is increasing, i.e. the population is aging.
What you didn't answer was, how do you differentiate between necessary utilization and unnecessary utilization?
I have always been under the impression that all this "skin in the game" stuff, and switching to HSA's and HDHP's was aimed at reducing unnecessary utilization, brought on by people being shielded from the real cost of health care, and seeking medical attention even when it is not necessary.
Am I wrong again, as usual?
I guess I really don't understand this stuff.
"the concept that "over utilization" of health care is a major contributor to the rise in health care costs, and mentioned by BC as necessary to reduce costs, I would like to know what data there is to support this claim?"
Marc, this has been documented for many years, and if you are so inclined you can find all the data you want. Thank goodness for the internet.
Couple of quick examples.
(1) In the 1970's the federal government sponsored a study of utilization under contract with the RAND Corporation. Results published starting in the early 1980's included the finding that outpatient utilization declined as patient cost-sharing increased - without adverse health consequence for the patient. In other words, some fraction of outpatient utilization was found to be sensitive to insurance reimbursement not solely to strict medical necessity. (Newhouse et al)
(2) In the late 1980's NEJM published a landmark longitudinal study of patients who had Coronary Artery Bypass Graft surgery. The findings were (a) for 1/3 of the patients the surgery was definitely necessary, (b) for 1/3 of the patients the necessity for the surgery was equivocal and (c) for 1/3 of the patients there was insufficient medical necessity to justify the surgery. Thus between 1/3 and 2/3 of these surgeries may not have been medically necessary. (Winslow et al)
(2) about the same time, the same researchers as in (2) pubished another study in NEJM, of patients who had undergone carotid endarterectomy. The results mirrored those for CABG - between 1/3 and 2/3 of these surgeries were not necessary, or the reasons for the surgery were judged equivocal. (Winslow et al) (*)
Why relate examples from years ago? To underscore the fact that excess utilization of health care, influenced by insurance coverage and reimbursement rates, has been well-documented for a long time.
(*) At that time, I worked at a large insurer, and happened to attend a meeting with the Medical Director of a very large group customer, accompanied by my company's Medical Director. During the meeting, the customer's MD tossed a copy of the "CABG" and "CE” studies from NEJM on the table and asked "what do you know about these?". My medical director glanced at the magazine and replied she was familiar with them - because she was a principal researcher and author of the articles! What a great meeting that turned out to be.
switching to HSA's and HDHP's was aimed at reducing unnecessary utilization, brought on by people being shielded from the real cost of health care, and seeking medical attention even when it is not necessary.
No, I believe you have it.
Just took us a while of back & forth to get to that point, but you are correct.
A clear solution to all this is to ensure every person get the precise care s/he needs when it is needed, nothing more & nothing less, and to make sure that care is delivered in the safest and most effective & efficient manner possible -- eliminating errors and unnecessary tests and procedures. Resources should be spent on making this happen and consumers should have the information they need to select the care plans and providers best suited to meet their particular needs. Teams of providers delivering higher-value care get the more referrals (and possibly higher compensation rates). Patients demonstrating a commitment to self-care have lower premiums. Payers profit would then increase through lower utilization.
There you go, everyone wins: Care safety and quality and efficiency continually improve as cost decline; the most competent providers gain competitive advantage and care plans gain without being perceived as the “bad guys.” Our country should be discussing how best to accomplish this.
DOES ANYONE REFUTE THIS PATH TO SOLVING THE HEALTHCARE CRISIS???
About one of John’s points:
any action having a prayer of reducing cost must reduce the per capita amount of money flowing into the system and that's messing with doctors' incomes
According to the new Porter and Tiesberg book, our current zero-sum game – where a gain to one side means a loss to another -- can be changed by redefining competition based on value. The solution I’m proposing incorporates this consideration. Where I do agree with John’s comment is that continuing to squeeze providers’ compensation in order to increase payer profits is self-destructive.
Anyway, there are a number of beneficial opportunities for payers, which focus on developing new business models; I’d be interested to hear your thoughts.
"every person get the precise care s/he needs when it is needed, nothing more & nothing less, and to make sure that care is delivered in the safest and most effective & efficient manner possible -- eliminating errors and unnecessary tests and procedures."
Steve, that describes an ideal, and is an admirable goal statement but I think is perhaps not yet a "solution". It's a bit like saying one's strategy at Wimbledon is to break your opponent's service. Well, yeah, that's the perfect strategy but now comes the the hard part - figuring out how to do it.
Thomas Edison said "invention is 1% inspiration and 99% perspiration". Figuring out how to do it is the 99% part. For example, how will the care I need be defined? Who will define it? How will the decision be made whether my need for it justifies my getting it? Will I have any say? How will the opinions of my doctor, a government fonctionnaire, a court of law, the medical literature, or a QALY score figure into the decision? These and many many others are the Tough Questions for which Concrete Answers are necessary to figure out how to implement the strategy - how to do it.
The answers need not be perfect in order to proceed, but they have to be pretty good. In fact, that's our present situation - what we have is not perfect, but it's pretty good (except, of course, for the cost).
Does that mean we stop reaching for an ideal goal? No. But we must recognize we won't reach the goal in a single step and in fact we may never actually reach an ideal state. And we must recognize that when our reach exceeds our grasp that does not mean we have failed.
John -- Great comments as usual. I would like to suggest that it would be useful to strive for continuous improvement throughout the system with respect to both cost and quality.
Some things are likely to prove very difficult and take a long time such as developing P4P metrics that doctors and hospitals could accept and embrace and reorganize the healthcare system to compete at the medical condition level like Porter and Teisberg suggest.
Some of the other things that I and others have mentioned previously could be pursued as discrete efforts. These include pricing transparency initiatives, malpractice reform, cracking down on fraud, high deductible health plans, a campaingn to increase the use of living wills and advance directives, and a better balancing of costs and benefits for care at the end of life to name a few. I could even support various individual mandate approaches to end free riding, especially with respect to hospital care.
I am not ready to pronounce our market based system a failure until it actually has a chance to function like a market which includes, importantly, good price and quality transparency.
One of my greatest frustrations is that many people tend to view the problems of the healthcare system as primarily a fiscal issue centered on insurance, expenditures, and provider compensation. As a result, when searching for solutions, there’s a great deal of focus on finding creative ways to “redistribute” the dollars through monetary policy. Unfortunately, this “misses the boat” because it gives relatively little attention to transforming healthcare delivery by obtaining and using sound clinical knowledge to drive ever-increasing care safety, effectiveness, and efficiency.
If we focused much more strongly on dealing with these clinical issues, we’d be asking different questions. Instead of trying to increase profits/income/revenue by figuring out how to shift costs, deny care through caps and exclusions on coverage, game the system through diagnostic & procedure code “optimization,” cherry-pick patients and members, submit fraudulent claims, over-utilize procedures and equipment, etc. – we would be looking for practical ways to help consumers avoid health problems, help patients get better more quickly and keep them better longer, enable and reward providers to deliver high-value care, empower consumers/patients to select the best plans and providers, etc.
As such, it seems to me that our country has to wise-up and re-frame the problem so better questions are asked more often. This means making clinical research, information-sharing, knowledge-building, and decision-support top priorities. It means having payers change their business models and providers change their practices to support these processes. It means redefining competition and empowering consumers through education and transparency. In other words, we have to shift our primary focus toward finding ways to support better development and use of evolving clinical knowledge by all stakeholders. Otherwise, we will continue down a road to disaster!
On our WellnessWiki, we offer nineteen tactics consistent with this approach.
All well and good, but, as John F has already observed, none of this is free, and none of these are concrete solutions.
IOW, who's going to pay for this risky scheme (with apologies to Algore)?
[Steve: I'm joshing with you on the "risky scheme" verbiage, just couldn't resist. But the question itself stands]
Steve,
Is anyone doing a good job of keeping people healthy at comparatively low cost -- Mayo, Cleveland Clinic, Kaiser? Are there any success stories overseas? I keep hearing from hospitals and doctor groups that the better job they do at keeping people healthy and cutting utilization of resources, the less they make in income. On the other hand, it seems that the original HMO capitation model creates an incentive to undertreat.
Porter and Teisberg's thesis of competition at the medical condition level certainly makes intuitive sense, but it seems so much easier said than done, especially for patients with multiple medical conditions that create all sorts of complexities in trying to treat them. Uneven patient compliance with doctors' instructions and not taking medications consistently are also not helpful to either the patient's condition or in trying to measure how well the doctor is doing in keeping the patient healthy.
I guess if fixing the healthcare system were easy, we would have done it 30 or 40 years ago! Probably the only thing most people can agree on is that throwing ever more money (as a percentage of the economy) at heatlhcare is not sustainable.
who's going to pay for this risky scheme
Interesting you should use that term.
I see health insurance news from other parts of the world, and particularly in Brit colonies the term "scheme" is used rather than insurance. Just recently insured a Brit coming to the states for a tour and wanted travel medical coverage. We swapped emails, and talked on the phone a few times. Every time he asked questions about the coverage he kept referring to it as a "scheme".
I wanted to correct him, but figured he would then want to correct my accent . . . so I left it alone.
100?
[Yes, John, it is. Congratulations! HGS]
100 posts. Wow. Not even counting the other post that has 30.
Isn't it interesting that the results of a single survey generated all this comment?
It's almost as though public opinion is not acceptable for what it is, instead we all (me, too) feel the need to explain it or rationalize it in ways that fit our own notions. Or, as Pontius Pilate is rumored to have said, "What is truth?"
Even so, I think the commentary here has been intelligent and on point & even the disagreements enlightening. No matter how many different opinions have been expressed, there really are people willing to listen to others and perhaps even modify their own thinking based on information or reasoning supplied by the group. I think that's just about the only way that, as a nation, we'll get to a consensus on health care.
One never knows when learning will occur, or where it will lead. I had a college professor once who kept track of unanswered questions that came up in class on one of the side-boards. At the end of one class, he said something like this "we started today with one unanswered question. Now we have seven unanswered questions. What a wonderful bargain." That insight was worth my tuition for the whole semester.
Uhhh, hmmm. I feel like Michael J Fox in Back to the Future, playing Johnny B Goode, when he suddenly realized everyone had stopped dancing. Er sorry.
Anyway, 100 posts is a real tribute to the readers of this blog, and I thought it was worth saying so.
[I agree! Thank you for your kind and wise words, John, and Thank You to all who've commented (so far -- please don't stop!). HGS]
Bob,
In the UK, the word "scheme" is generally used to mean what we would call a "plan."
We say a raise in pay; they say rise.
We say swim suit; they say swim costume.
We say exit; they say "way out."
There are lots of examples like this.
Perhaps I need to don my costume to offer my scheme's in hopes of getting a rise.
Way out!
note to HGS, don't even bother . . .
HELP … I’m trapped in a blog and can’t get out!!! (haha)
Yes … This is a great conversation. There’s not enough deep dialogue like this in our “sound bite society,” and there’s not enough sincere, innovative, critically thinking in our nation of empty campaign promises, dishonest business practices, manipulative advertisements, non-accountability, lobbyist-driven government, and extremist views of right & wrong. But I digress …
“none of this is free, and none of these are concrete solutions … who's going to pay for this risky scheme”
The 19 tactics we spell out do not constitute a “risky scheme” in my view. What’s risky is status quo as we wait until the Medicare debt and percent of GDP for healthcare help collapse our economy, Medicaid becomes insolvent, few employers fund health plans for the employees, the number of uninsured continue to grow, our emergency rooms become ever more ineffective, care quality continues to deteriorate … and so on.
Making those the 19 tactics of our proposed solution more concrete requires the collaborative efforts of all parties involved in healthcare. We are just pointing toward a path that has great potential for solving the healthcare crisis by focusing on tying income and profits to the pursuit and demonstration of continuous improvement in care safety, quality, and efficiency. I don’t see what’s so risky about that approach.
So, how do we pay for these tactics? Well, I’m a healthcare practitioner, scientist, writer, entrepreneur, and technology inventor, but I’m not an economist. While I can identify some of the most important things to fund, I require input from others as to the best ways to fund them. So, let me spell out some of what’s needed to pay for the proposed solution and I’d appreciate your help in answering the question of how to pay.
The most important thing we should do is fund collaborative (practitioner-researcher) research focused on identifying the best ways to keep people healthy and treat specific patient types through development and use of evolving evidence-based guidelines. There are working models of this tactic in several research networks in the country, and HMOs such as Kaiser and Geisinger Health System, as well as RHIOs, are able to do the same sort of collaborative research (see Collabaration). Health information technology, running meetings, personnel, and administrative overhead are the main costs of collecting the health data and doing the research, as I understand, and, depending on the situation, funding includes grants from government, foundations, and payers.
While expansion of similar programs/networks would require a re-focusing of Federal monies on such activities in the short-term, to be sustainable long-term requires self-funding. An example is a new RHIO as a “community healthcare utility” model (discussed in the same link above). Another example Geisinger looking to sell some of its guidelines (clinical order sets) based on their research to hospitals for developing programs of evidence-based care. And, I suppose, still another funding mechanism could come from membership fees from providers who see that joining such a network results in competitive advantage though delivery of better outcomes.
Paying for consumer education and wellness/prevention programs tactic is also necessary. Employer-based wellness programs are paid by the employer and there is often insurance coverage for some well-care, which may need to be expanded. And reducing premiums for people who take good care of themselves by complying with doctors’ orders makes sense to me, although I don’t know enough about insurance to suggest how to fund it. Public funding of community-based wellness programs is also a reality. But we need to fund more research on finding the best ways to make self-care effective (i.e., evidence-based well-care guidelines); I suggest this money come from government, corporate, and private grants.
As for the personalized care tactic, we should continue to research ways to make genetic information more useful in preventing and treating health problems. Funding is currently coming from biotech companies.
Funding possibilities for the rest of the 19 tactics seem to fit into the categories mentioned above: Grants, insurance, and self-pay.
Bob,
You said: “I keep hearing from hospitals and doctor groups that the better job they do at keeping people healthy and cutting utilization of resources, the less they make in income. On the other hand, it seems that the original HMO capitation model creates an incentive to undertreat.
I agree. This is where an effective P4P strategy would be helpful, although the challenges with implementing a decent P4P strategy are substantial.
“competition at the medical condition level … seems so much easier said than done, especially for patients with multiple medical conditions that create all sorts of complexities…Uneven patient compliance with doctors' instructions and not taking medications consistently are also not helpful to either the patient's condition or in trying to measure how well the doctor is doing in keeping the patient healthy.
Again, we agree. But if the multidisciplinary teams focus on patients with a particular health problem/condition and all the concomitant problems typically associated with it, such complications can be addressed. I’d also include a team’s ability to provide effective well-care as one of the competencies they must develop.
“most people can agree on is that throwing ever more money (as a percentage of the economy) at healthcare is not sustainable.”
Yup. The money should be spent wisely, not thrown around foolishly, i.e., it should be spent on sincere efforts to improve safety, quality, and efficiency continually, and on rewarding those who make that happen.
Bob,
You said: “I keep hearing from hospitals and doctor groups that the better job they do at keeping people healthy and cutting utilization of resources, the less they make in income. On the other hand, it seems that the original HMO capitation model creates an incentive to undertreat
Actually, I didn't post that.
Tried finding it, but believe it was either Marc or John.
At this point, it could have been Mother Teresa for all I know.
Actually, that was BC.
Or is that Mother BC?
BTW - Here are some numbers opposing the survey we've been discussing:
A national survey found that 55% of Americans were dissatisfied with the quality of health care in 2004, up from 44% in 2000 [The Kaiser Family Foundation/Agency for Healthcare Research and Quality/Harvard School of Public Health. National Survey on Consumers’ Experiences With Patient Safety and Quality Information. Washington, DC: Henry J. Kaiser Family Foundation; 2004. Publication No. 7209]. These findings were recently confirmed by another survey in 2006 showing that 56% of Americans are dissatisfied with the overall quality care and 82% are dissatisfied with its cost [see http://abcnews.go.com/WNT/print?...rint?
id=2570911].
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