At the risk of the inevitable new post from Charles Wulff, here is the President explaining sacrifices we'll have to make:
Asked about sacrifices Americans might have to make in terms of access to specialists or intensive treatment at the end of life, Obama insisted that no one would have to give up any useful medical service under the plans being debated in Congress.
"They're going to have to give up paying for things that don't make them healthier," Obama said, claiming that only waste needed to be cut from the system. "Speaking as an American, I think that's the kind of change you want..Why would you want to pay for things that don't work?"
"Can I guarantee that there are going to be no changes in the health-care delivery system? No, the whole point of this is to try to encourage changes that work for the American people and make them healthier," Obama said later.
While this sounds well and good, Obama is selling an imaginary free lunch here. No matter who or how, what he is proposing means someone other than an individual's personal physicians and the individual himself will be making decisions about their medical choices. While private insurance (and if it happens, the "public plan") also restricts what a person can have done, a better way to improve health care would be to make health insurance more portable and give people more choice than just what their employer offers, while switching payment methods to being focused on outcome rather than procedue. This would mean that people would be making decisions on what they would be covered for in advance when they pick their insurance, and once they have to make medical decisions, it will be the doctor who knows them best helping them decide what the best use of their money is, instead of some distant government bueracracy.
Source: http://www.politico.com/news/stories/0709/25307.html#ixzz0M73ZsdUQ
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Sweet, a post directed right at me! I love being noticed.
ReplyDeleteAnd off of your other comment, I agree that it would be better if the payment plan wasn't based on paying on the number and cost of treatment, but on results. But I will raise the point of how do you define "outcome". If I die, even if the doctor did everything perfectly and efficiently, should he not be paid? Or if I get lucky as a doctor and manage to resuscitate a man who has a heart attack by guessing, should I be paid? Outcome is so general, demanding that you pay of the outcome of individuals would be a mess. But if you try and standardize it, then it would begin to become the comparative effectiveness, as you would have a wide arching basis for medical treatment that would be paying based off of how well a certain treatment method works, and not paying if it doesn't work.
And if Medicare and Medicaid switch over to paying based off of "outcome", wouldn't that be government setting standards based off of effectiveness, as it would be government programs that are determining payout based off of effectiveness/outcome? Even if it set the standard for the rest of the industry, it would still be a government group determining if a treatment is effective.
And medical procedures are already determined by distant bureaucracy, both private and government. The AMA, insurance companies, the FDA, the numerous ethics committees and organ transplant groups, hospital administrators, congressional bans and limits, presidential executive bans, and supreme court rulings all limit doctors and restrict what doctors can and cannot do. To act like this will be a new thing with a public plan or a comparative effectiveness group would be absurd.
And why would a plan that would pay you for an effective treatment stifle experimentation? If I go out and come up with something that works better, I would be creating a more effective treatment. Comparative effectiveness would demand that my procedure be covered as it is a more effective method of treating things. In medicine, there is only two reasons that experimental stuff is ignored or dropped: It DOESN'T work (or at least not better than what is currently done) OR it is expensive and insurance or the patient won't/can't cover the cost. Comparative effectiveness would actually recommend a good new procedure and possibly require it be covered by insurance companies much earlier than before, which means that it would be more accessible a lot faster (in the past, it took forever for procedures to move into mainstream because of cost having to be covered by the patients alone, thus making people less willing to pay).
Finally, I have no problem with insurance being more mobile or more varied and accessible. It would make sense that your job isn't what allows you to stay healthy, especially when you consider that just because you are not working doesn't mean you will get sick (in fact, you actually are more likely to get sick, go figure! Explains why I always get sick during vacations...) But I don't see why you can't make a basic government plan available as one of the options. It would be completely separate from ones job, and if you don't like, buy a private insurance. But if you can't afford it, then at least you have something.
These longs posts are hard to respond too because I have to search through and make sure I address every point. I'll try yet again. Feel free to let me know if I missed something:
ReplyDelete1)The way Medicare and Medicaid's payment plans would be changed would be through giving the Medicare Payment Advisory Committee real power. Right now, this bipartisan, both Congressional and Presidential appointed group of doctors and health care economists gives recommendations to Congress that are summarily ignored or watered-down to suit political constituencies. Republicans and conservative democrats in Congress want to give them the ability to make their recommendations in one package that would have to be rejected or accepted up-or-down, as wells as completely independent powers on the margins. You supported a similar group for comparative effectiveness, but this group already exists, would change payment schemes, but would leave health decisions up to people and their doctors.
2) You are right, paying based on outcome is messy. Outcome depends on the eye of the beholder. But this is just like any other market. Right now, health care is so distorted by invisible taxes and subsidies. If we replaced all of those and replaced it with one flat subsidy for individuals and families, as John McCain proposed last year and moderates in Congress are proposing this year, or simply made ALL health care expenses up to a certain amount tax exempt, but again at the individual level, people would feel the real cost of their health care decisions and would be less likely to jump straight to specialists or risky, ineffective procedures. As I said before, this makes health insurance like any other market. Not to mention that these plans increase labor mobility, would limit health care gentrification, and would bring additional money (primarily from the rich who are using the employer-based tax exemption to their advantage) into the federal coffers.
3) Addressing bueracracy, just because the government has done it before doesn't make it right. Government regulations simply distort the market and prevent smaller companies similar to Kaiser Permanante, which is the closest thing to a "Sam's Club" of health care that exists, from popping up.
4) Private-sector bueracracy is market based, and while they are currently distorted by perverse public incentives, the simplification of those incentives would make them react like any other service provider.
5) Experimentation goes back to incentives. Sure, it wouldn't eliminate all experimentation, as universities and bigger hospitals who can afford to risk money that they will either get fined or won't get in subsidies (depending on what style of "comparative effectiveness" they choose to use) by investing in this process. Smaller providers, however, would now have a monetary incentive to go with the "safer" procedure, even if the doctor KNOWS that he is right. I'm not just talking about big experiments...I'm talking about on-the-spot decisions to try something different.
6) Which brings me to the point that comparative effectiveness, to be feasible, would require massive interference at the federal level. Huge costs and paperwork, as you see in Britain and Canada. Different studies have estimated this at different amounts, but it would further health care inflation. This is an on-the-margins thing, but just another negative in the "we'll control costs" lie.
Holy crap, I had to go to two. Let's try to keep these discourses more focused from now on, Charles. Anyways, here's my last point:
ReplyDelete7) The argument that a "public option" increases choice is a red herring. That is an argument for a public option in every market. That is an argument for Socialism, plain and simple. This is not rhetoric, it is fact. If a public option increases choice, why doesn't the government provide a state-owned company in every other area that is important to people. BECAUSE IT DRIVES PRIVATE COMPANIES OUT, AND PRIVATE COMPANIES ARE MORE EFFICIENT. Even liberal economists have admitted what President Obama hasn't, and that is that a public plan would force some people who currently have better, private insurance onto it for two reasons:
A) Many smaller-to-medium sized employers would drop their private companies for the cheaper public option.
B) Because the public plan would be funded by public coffers and manipulated by interests in Congress, it could artifically undercut the costs in the market, just like any firm with price-controlling market power, and as other firms rapidly cut cost and go under, some people who would be willing to pay more for better insurance would be forced onto its rolls. This would create a chain reaction where other insurance agencies
In the end, a public plan, unless it is absolutely bare bones, which Congress would never allow it to be, would decrease choice and lead to greater gentrification, as only the rich and upper-middle-class could afford private insurance without breaking their backs. See Germany and France for perfect examples of countries that have public plans, as well as massive health care gentrification.
Sorry, I was replying to two posts (this and the previous healthcare one). Maybe I should start my own blog and just put links up to save you some frustration. ...Anyway:
ReplyDelete1. I agree with you. Plain and simple. The group should be able to make independent decisions, instead of congress. I will point out that this board has suggested payment based off of the effectiveness of treatment in the past as a way to prevent excessive expenditure or failure to provide necessary treatment.
2. I still would like you to explain how you would pay by outcome. If it is messy, as you admit, even if you followed the idea of subsidizing private insurance (which I honestly would not have an issue with, as long as it is adjusted so as to grow as prices naturally increase) you would still need some standard to insure that people knew what procedures were more effective and that insurance companies would have incentives to pay for them.
3 & 4. I was not saying that they were good things, but simply that regulations from both the private and public sectors control both insurance and practice of medicine. If the effectiveness of the treatment was what decided payment instead of all these groups, I would think it was making it more simple.
5. In medicine, the concept of a "off the cuff" procedure is bogus. If someone is doing something, it almost always has some precedence. A doctor, if they are doing a "spur of the moment" action, is usually doing something that stems from some previous procedure, or is an extension of the current procedure. And yes, under some countries who prescribe to comparative effectiveness, they do limit what experimental stuff can be done. But this is also because the also limit the costs they are willing to cover as well, which IS NOT comparative effectiveness (see Britain). Japan currently runs a system (and in fact, has universal healthcare) that allows for experimentation and echoes the comparative effectiveness that I discussed. Furthermore, there are VERY few insurance plans out there that will EVER cover experimental treatment, and if you have these plans you could likely afford the treatment without insurance anyway (congressional health plan for example). So please tell me why we have experimentation now in a market that doesn't pay for it?
6. Something I still do not understand is why someone I know to have argued for transparency in the markets seems so vehemently against knowing the full truth about what you are paying for when you step into the doctor's office. You are arguing against something that would prevent people for paying for pills that don't work as well but cost more, about paying for procedures that could do nothing or little to help, or paying a doctor who likes to run 50 tests "just to be safe". Wouldn't you want to know if you were getting your money's worth?
7. Your right, that is a good point. The government should stay out of all fields of the market, because it obviously undercuts them, just like the post office undercuts UPS and DHL. Or how the military undercuts private contractors. Or why the bottled and purified water companies are having it so hard because the government provides clean water. Or hoe PBS keeps destroying the other Television Networks. Just because the government enters the market does not mean it will be destroyed for the private sector (though I am not denying that it could). It usually allows people that can't afford the alternatives to have access to something (i.e. send a letter) if not the best version (sending a letter overnight delivery). I will point out that when it comes to a market that is dealing directly with the Life (as in the first of the three big ones "Life, Liberty, and Pursuit of Happiness"), you can't then argue that it should have completely free reign or that the government has no right to protect that. Now I am not saying that we need Obama's plan (I had no problem with McCain's plan except that it relied on removing the Tax exemption on employers and then didn't provide a comparable subsidy level- I.e. companies would drop the insurance and then the employee would not be able to afford with the subsidy their own plan in some cases) but I will say that it is unfair to argue that healthcare should be entirely private.
ReplyDeleteAnd in Germany at least, it is not because the cost of the private insurance is so high, but instead because the government won't allow it to be purchased unless you make above 75,000 euros a year. So it isn't because the plan drove the costs up, but because the German government is being really stupid and is actually forcing gentrification.