Sunday, May 29, 2016

The US health and social service system is evil

I have often written about how our health system is “deeply flawed”, but I realize that there are many ways in which this is a grand understatement. I initially intended to call this piece “health insurance companies are evil”, but realized that this singled out but one player. I mean, insurance companies are at least as evil as other parts of the health and social services sector, but naming only one part both does a disservice to that part, which is acting rationally in relationship to the other aspects of the system, and tends to forgive the others.

The thing wrong with our health system is that it is a mess; there are dozens or hundreds of ways to have health insurance coverage, or not, and each costs a different amount and covers different conditions, for different percentages, with different amounts of coinsurance and co-payment and deductibles. A single-payer health system, where everyone is covered with the same benefits for the same care (all that is needed, none that is not) and payments tiered to income, is the only rational and effective way to make sure that we have the possibility of quality health care. There can be no quality without equity. While I will not spend more time here making this case, because I and others have previously done so extensively, I will refer to it.

What is evil is how the system affects our actual people. However, people are not really ever seriously considered in “health reform” (or social service “reform”). Yes, people’s suffering sometimes gets mentioned by political candidates, who note that some people are paying too much or are not getting care. Indeed, this has been a big theme of Republican candidates who are critical of Obamacare, but whose only plans are ones which will make it a lot worse for most people. Actually making the system work for people is never really on the table, because when the political negotiations begin, the big players (insurance companies, providers, drug companies, device manufacturers, etc.) enter the picture.

Let’s get right down to it: people in the US, even those who are citizens, just do not get the coverage and services to which they are fully entitled, not to mention the coverage and services that they actually need. You have to sign up for Medicare, pay for Part B (which is what covers everything except inpatient hospitalization, including doctors’ fees), choose and pay for a Part D plan. If you are lucky enough to be able to afford one, you have to look through a maze of possible Medicare supplement plans and hope you chose correctly, given the multiple variables of your health status, the benefits profile, where you live, your actuarial as well as self-perceived probability of getting ill, and what you can afford. Even Social Security, a benefit that you have paid into for your entire working life, requires you to sign up and show you are eligible. This is nonsense; there is no reason it should be this way. We start with a non-system that does not cover everyone, provides inadequate coverage for those who do have it, and makes it difficult to sign up, presenting numerous obstacles which allow people to fall through the cracks.

Actually, this is more than nonsense; to the extent that people pay the price of inability to navigate the system with their health, it is evil. It would work, and be much simpler, if everyone, when they retire, got Medicare. And if Medicare covered everything for everyone wherever they live. Why not just make sure everyone gets Social Security? Why make it the responsibility of the person to demonstrate that they not only are truly eligible but that they can get through a jungle of options, often confusingly computer based, when they are getting to the end of their careers? Of course, if we had a single payer system, everyone would be in and there would be no change when you retired or became 65; you’d already be in a system in which everything you need and nothing you don’t need is fully covered.

Actually, in a good system you’d be better than “fully covered”. You’d be covered appropriately; you would, whoever you are, get the care that you need, but you would not be eligible for coverage for things that you don’t. We would have a health system that provided necessary, appropriate, and proven diagnosis and treatment for people, rather than emphasizing the provision of services which were most profitable to the providers. Insurers would not do their best to risk-select, would not be able to charge more for some people than others (and they can under Obamacare; they have to cover you even with a pre-existing condition, but can charge more), and would not even have to be for-profit. I favor a single-payer health care system such as Canada’s, a (fully-funded) Medicare for all, as does Sen. Sanders. But there are other reasonable alternatives; Switzerland, for example, has, instead of a single payer, multiple insurance companies. But these companies have to cover everyone, provide the same benefits, charge the same price, and be non-profit.

Critics of Sen. Sanders often say that a Medicare-for-All system would bankrupt us. This is also nonsense.  It presumes the built-in profit for insurance companies. It presumes that we would continue to pay the most of the most complex and high-tech procedures, and let providers (via the complex system of the RUC --  Changes in the RUC: None…How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013, which essentially sets the Medicare rates on which all other payments are based) set the rates for their own procedures. The evidence is in every other wealthy country, all of which spend much, much less on health care and have much, much better outcomes. They also provide much better social services, not only for the needy and the poor, but for everyone. Retirees get their pensions. And they keep their health care.

The system works in these other countries; that is, if your interest is in ensuring that everyone gets the health care they need, the pension benefits to which they are entitled. If your interest is in maximizing the income of (some) providers and the profit for insurance and drug companies, then they don’t work as well. So I guess our system is not necessarily evil, it depends upon your values.

But, then, I would argue that the values on which the system is de facto based, though, are evil ones.

Friday, May 13, 2016

Good Enough for Government Work: Quality, Cost, and Gaming the System

The entire text of the "Good Enough for Government Work: Quality, Cost, and Gaming the System", the 23rd Odegaard Lecture from the 27th Primary Health Care Acces Conference, is available now as a Google Doc at this link:

The link will continue to be available on the right side of this blog page.

Sunday, May 1, 2016

Good enough for government work: Quality, Cost, and Gaming the System (Part 4 of 4)

This is the fourth and final part of the 23rd Charles Odegaard Lecture, "Good enough for government work:Quality, cost and gaming the system. I will put the entire talk up as an attachment soon.

Is this really true? Aren’t some of our costs “our fault”, or at least “their fault”, that is other people? What about those folks who are “gaming the system”, by holding out on buying insurance until they get sick? Aren’t they driving up costs? Insurers like Aetna and Anthem make the accusation that people are misusing Special Enrollment Periods (SEPs) for this purpose. This is debunked by the evidence, cited by Michael Hiltzik of the Los Angeles Times, but even if they were, they’re poor people trying to get by! Wondering if they can put off buying health insurance so that they can pay the rent! Who is really in a position to develop and implement strategies to “game the system”? 

Unsurprisingly, as Hiltzik also reports, it is the insurance companies (as well as big health system providers) who are masters of these strategies. Besides, if we have concern about “buying to use” behavior, the best answer is to get rid of the jumble of insurance companies and enrollment periods and have one national health insurance plan that has, in the words of the recently deceased Quentin Young, “everybody in, nobody out”.
The most amazing thing about all of this, the way in which the system is gamed, is the way it transfers public money intended to provide healthcare for people into private pockets far in excess of the cost of providing that care. Himmelstein and Woolhandler provide us with data that shows that we already pay for a national health system, with over 50% of “health” costs being borne by government, far over 60% if we count the loss of revenue from employer contributions to insurance being tax deductible, but we still don’t come close to covering everyone, because our system is so inefficient, and so much boodle is being raked off.
Nowadays, when we hear the phrase “good enough for government work”, we tend to think of something that is poor quality, or only just meets the minimum standards set by government. The Urban Dictionary defines the phrase as “Probably not the best, but what the hell, at least we got the job done to minimally acceptable standards.” And, yet, when this phrase first came about it was a compliment; it meant that the government set minimum standards of quality that had to be met, and if you had someone (say a contractor) doing work that was “good enough for the government” it meant that it met those standards of quality, that they weren’t ripping you off by doing shoddy work. What we have now is our publicly-funded health system being cannibalized by profiteers, and enabled by a government that often seems to care more about cost than quality.

Charles Odegaard, the medieval historian and former University of Washington president after whom this lectureship is named was, and I quote from the Coastal Research website, “an impassioned proponent of the idea that every school within a university should be engaged in the advancement of society in the communities and regions that surrounded it. As a result of Dr Odegaard’s leadership, UW became a leader in the decentralization of medical education, including the unprecedented commitment to training physicians from and in the surrounding states of Alaska, Montana, Idaho and Wyoming.” [1]

There are great positives to decentralization, whether for education of doctors or for administration of social programs. It can decrease the cost of large, unresponsive central bureaucracies, and put control in local areas that are more knowledgeable about and responsive to the needs of their populations. There are, also, risks. Sometimes control at the local level is more about maintaining the power of one sector of the community at the expense of others; one just has to look at localities and states in the South in the Civil Rights era defying integration (or, perhaps, many states and localities more recently). More to the point of this talk, there is the risk that smaller, more decentralized activities can be more easily underfunded. Think about the deinstitutionalization of people with severe and persistent mental illness toward the end of the 20th century. When I was in medical school, I was taught that 1 in 3 hospital beds was occupied by someone with schizophrenia. That is certainly not true today, because of deinstitutionalization. And so we do not have the horror of people with mental illness warehoused in enormous facilities, but we also do not have anywhere near the degree of community-based mental health services that would allow them to live successfully in the community. We have people with mental illness living on heating grates and under bridges and, according to a June 2015 article by Matt Ford in The Atlantic, our nation’s largest mental hospital is a jail (absolutely believable to anyone who has ever worked in one).[2]. It is only ok to decentralize when we can assure that necessary programs will be maintained and will be well funded. We have long since privatized the health care in most prisons, and there is a (to me) disturbing movement to privatizing prisons altogether. Cost, again, trumps quality. Especially, of course, if the prisoners are mostly “not us”. Seeing a trend?

So…is it possible to have quality and still reduce costs? Of course. Our system is not only financially inefficient, and the victim of massive skimming by the private companies, but it is one which is geared to care for individual patients rather than populations; where there is not rational allocation of resources to the areas where they will do the most good, but rather decisions made for each individual, often where the provider has a financial incentive to do more. Oregon’s CCOs, a kind of state-sponsored but decentralized (there are 15 in the state) ACO designed only for Medicaid patients, have provided some movement in this direction, but they are limited because they are, in fact, only for Medicaid patients. This permits skimming, as we see in recent data that shows that the places long touted for their efficiency and low cost for Medicare, like Grand Junction CO and Rochester MN, are among the most expensive for private insurance. The same characteristics, integrated health systems which control most of the care in a community, that allow them to be efficient with fixed Medicare funds, also allow them to raise the rates for private insurance. Gaming the system.

We could have a good health care system. It needs to be built upon quality, and quality has to be based on consensus, and has to apply to everyone, rich and poor, young or old. It cannot be segmented into different versions of quality for privately insured, Medicare, Medicaid, and uninsured people. The “how-to” is not hard; other countries have shown us how. The money is not hard, we are already spending excessive amounts. What we need is the will. 

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