National health spending rose a slight 3.9 percent in 2010, as Americans delayed hospital care, doctor’s visits and prescription drug purchases for the second year in a row, the Obama administration reported Monday.
The recession, which lasted from December 2007 to June 2009, reined in the growth of health spending as many people lost jobs, income and health insurance, the government said in a report, published in the journal Health Affairs.
There are a couple of takeaways from this news.
First, the reduction in spending on healthcare could mean a welcome, albeit temporary relief to those governments and organizations that pay for healthcare….BUT…no real relief for state and local agencies which provide/finance healthcare for poor people. Recessions, of course, result in greater numbers of people qualifying for government-supported care.
The other point is a reminder that some portion of healthcare services are discretionary. When healthcare spending was growing by 10 percent or more each year in the 1980s, that growth probably wasn’t driven by an increase in the need for services. Likewise the slower growth over the last several years is probably not due to the population getting healthier and needing fewer services. Instead, people moderated their demand for healthcare. They put off diagnostic tests, or did not follow through on treatments or prescriptions. Going in the other direction, hospitals routinely see increases in elective surgeries near the end of a calendar year, as people have already met insurance deductibles, and decide to seek care before those deductibles are reset in the new year.
Is this good news? Not necessarily. To the extent the people put off truly necessary tests and treatments, those delays may cost us more in the long run. To some extent, though, tough economic times force us to be more cautious about discretionary spending, and there may be very little impact on long run health status. There is the old saying that if you get a cold, it will take 7 days to go away, but if you see a doctor you’ll be cured in a week! One important element of effective healthcare reform is to introduce that sense of caution in our population. It is a delicate balance – not wanting to interfere with early testing and early, cost-effective treatment, but also discouraging care that has less impact on long term health.
Prices for medical care services and supplies also stayed roughly on par with general inflation during this last year, which is a change from the decades of the 1980s and 1990s where the medical care component of the consumer price index routinely outstripped regular price increases.
I wouldn’t have to polish my crystal ball very much to predict that spending increases for healthcare will pick up speed as the economy recovers. This remains the single most important issue in our nation’s federal deficit struggles.
When I went into solo practice of internal medicine in 1981, it was very easy to get a doctor to see a Medicare patient. All I had to do was make a phone call. A courteous receptionist answered. If the doctor couldn’t come to the phone right away, I could count on a prompt callback.
Consultants saw patients quickly, and generally called me to discuss their findings and advice. And very often there would also be a letter in the mail: “Thank you for referring this delightful patient to me.”
How things have changed! Now a doctor gets the phone menu, just as the patients do, and it often ends in voice mail. It might be a few days before a staff member calls back—usually with the news that “we are not accepting any new Medicare patients.” At best, my patient might be offered an appointment in several months.
One very fine gentleman, who had recently moved to a rural area, found it easier to fly to Tucson to see me than to get in to see a local internist. That was in 2009. Recently, he has become unable to travel, so I needed to find him a local doctor.
I tried to expedite matters by ordering him an immediate diagnostic test: an abdominal CT scan. I don’t think anyone could argue that it wasn’t indicated under the circumstances. One little problem: I am not enrolled in Medicare and don’t have the proper government-issued number to enter into the computer. A license to practice medicine is not enough. This National Provider Identifier (NPI) is supposed to protect the system against being defrauded. Without that number, the imaging facility could not get paid by Medicare.
“Why not use the radiologist’s number?” I asked. After all, he was the one who would get paid. Nope, a referral was required. How about a self-referral from the patient? Nope, we can’t allow patients to decide what tests they need. “The patient is willing to pay for his own test,” I said. Nope, if he’s on Medicare, they aren’t allowed to take his money.
They gave the patient 24 hours to find a properly enumerated doctor to countersign my order. Fortunately, he found a specialist willing to do so, and assume potential criminal liability for committing “waste, fraud, and abuse” by ordering a “medically unnecessary” study. (Fortunately for the patient, he turned out not to have cancer, but that could be bad news for the doctor.)
So this is the status of retired Americans. They can’t just walk into a facility and request a medical test, and pay for it with their very own money.
A man may be qualified to pilot a 747 across the Pacific, but once he’s on Medicare, he is unfit to make an unsupervised decision about his own medical care.
I did find my patient a doctor. None of the internists within a 150-mile radius who “take Medicare” are willing to take on a new Medicare patient. But through the website of the Association of American Physicians and Surgeons (www.aapsonline.org), I found a link to the Medicare carrier’s list of opted out physicians. They don’t “take Medicare,” but many are pleased to see older patients, for a reasonable fee. There was one internist on the list, 150 miles from my patient. She has a courteous and helpful assistant who actually answers the phone, and told me the charge for a new patient visit: $300.
Things could be worse—and already are much worse in Canada. The “soul-destroying search for a family doctor” is described in the Globe and Mail on Aug 21. The Ontario government’s program called Health Care Connect manages to link only 60 percent of patients with a doctor—although you might find a concierge doctor for $3,000 a year.
That’s the cost of medicine when it’s “free”—if you can find it at all. If ObamaCare is implemented, all Americans will be in the same boat. And guess who will get thrown overboard first.
Some new data out on Small Area Health Insurance Estimates from the census folks.
They have a tool there you can use to look this up yourself, but what I get is that for children (age 18 and under) in Pennsylania, Allegheny County is tied with Montgomery for the lowest percentage without health insurance at 3.9%. The highest: 10% in Lancaster County. Data is for 2009.
The United Kingdom, where, on average, people live longer than in the U.S., spends only about 9 percent of gross domestic product on medicine, compared with our 18 percent. The British control costs in part by having the will to empower a hard-nosed agency, the National Institute for Health and Clinical Excellence, to study treatments and declare some ineffective. Some hope the United States will create a similar agency, but I fear it would be hopelessly politicized and declawed.
My solution: admit we are cost-control wimps, and outsource our treatment evaluation to the U.K. Pass a simple law saying Medicare (and Medicaid) won’t cover treatments considered but not positively appraised by the Britain’s national health institute.
Even better, use clinical evidence evaluations of the British Medical Journal. They’ve classified more than 3,000 treatments as either unknown effectiveness (51 percent), beneficial (11 percent), likely to be beneficial (23 percent), trade-off between benefits and harms (7 percent), unlikely to be beneficial (5 percent) and likely to be ineffective or harmful (3 percent). Let’s at least stop paying for these last two categories of treatments! And to put pressure on doctors to collect evidence, let’s stop paying for “unknown effectiveness” treatments after 10 years of use.
Suppose you went into a grocery store, and found no prices on anything. You ask a clerk how much five pounds of potatoes would be, and he asks you whether you are 65 or older. Youre taken aback, but you tell him you are 64, and he asks whether your income is less than $40,000.00 a year. Startled, you say it is more than that, and then he asks whether you have food insurance. Why would the
price of potatoes depend on the buyers age, income, and insurance status, rather than on the cost of growing, transporting, and stocking the potatoes? That would be absurd.
Yet thats how it is with medical care. I would be unable to find out, for example, the cost of an echocardiogram from the hospital where I did my residency. The price is different for different people. The government instituted this ridiculous situation, in 1965, with Medicare and Medicaid. There is a lot of mythology about these programs, but few people understand them like the physicians who are on the front lines actually seeing the patients. For some of them, it has been a gravy train. They game the system. For others, it has been a disaster to go through medical school and residency, and come out a de facto servant to government programs, but of
course, without benefits or retirement. If you are scrupulously honest, these programs will bankrupt youeven while turning you into Public Enemy #1.
Senators Ron Wyden and Charles Grassley have put forth the Medicare Data Access for Transparency and Accountability Act (the DATA Act) to open a database so that everyone can see how much money Medicare has sent to any physician enrolled in it. Regardless of the cost to provide medical services, the price the taxpayers are forced by the government to pay for other peoples medical care has gone down and down per procedure, per diagnosis, per office visit.
The public wont see that, but it will hear about some isolated cases; for example, an Oregon neurosurgeon who allegedly performed multiple spine surgeries on the same patient, or a Florida physician accused of $3 million dollars in Medicare fraud.
Gaming the system is fraud. But the biggest fraud is the one perpetrated on the working people of this nation who are forced to pay for other peoples medical problems. When Medicare was first instituted, Americans were reassured that it would never cost the taxpayers more than $9 billion a year. It is more like $500 billion a year now.
Patients learn to game the system too. Workers must pay through their taxes for even the most trivial complaint when someone on Medicare makes an appointment for it; say for a cosmetic skin lesion that has been present for 30 years without causing any problem. Working people are also forced to pay for the consequences of other peoples smoking, excess drinking, or risky lifestyle choices. Thats fraud, perpetrated by the government on taxpayers. Its hidden behind political smoke and mirrors.
Amazingly, we managed somehow for 189 years after 1776 without Medicare and Medicaid, and things were getting better and better until Lyndon Johnson came up with a good fraudulent vote-buying scheme, and then a lot of people decided there was money to be made off medical problems with the taxpayers the losers.
So, Wyden and Grassley, open your database. But include a list of all the procedures and diagnoses, and what Medicare and Medicaid actually send the physicians as reimbursement so people can see that physicians who spent years of their life in training while incurring tremendous debtare paid about the same as auto mechanics. And also account for where the rest (about 80%) of the
$500 billion goes.
That would be a good start for medical price transparency. And a good precedent for another database, one detailing just how much value politicians give taxpayers who pay their salaries.
About the Author:
Dr. Tamzin Rosenwasser earned her MD from Washington University in St Louis. She is board-certified in Internal Medicine and Dermatology and has practiced Emergency Medicine and Dermatology. Dr. Rosenwasser served as President of the Association of American Physicians and Surgeons (AAPS) in 2007-2008 and is currently on the Board of Directors. She also serves as the chair of the Research Advisory Committee of the Newfoundland Club of America. As a life-long dog lover and trainer, she realizes that her dogs have better access to medical care and more medical privacy than she has, and her veterinarians are paid more than physicians in the United States for exactly the same types of surgery.
I find the sentiments in the quoted passage objectionable for two reasons. First, preventative health care is not ‘everyone’s business’. Individual adults have primary responsibility for their own preventative health care because no-one is better able to exercise that responsibility than they are. Individuals who are persuaded that preventative health care is a collective responsibility could be expected to look increasingly to the various levels of government, non-government organisations, health professionals and practitioners, communities and families – everyone except themselves – to accept responsibility for what they eat, drink and inhale.
Second, the goal of making Australia the healthiest country by 2020 is being put forward as though it is self-evidently desirable collective good that should be pursued by any and every means available to everyone. The goal is not self-evidently desirable. Individual health is not a collective good. And the end does not justify the means that are being proposed to pursue it.
If you delve behind the spin about making Australia the healthiest country by 2020, the underlying goal seems to be to raise average life expectancy in Australia to the highest level in the world by reducing the incidence of chronic disease. What does this entail? It would be hard to object to the goal of enabling individual Australians to reduce their risk of chronic disease. The problem is that the government’s strategy is more about achieving national goals than providing better opportunities for individuals – more about behaviour modification than about ‘enabling’ individuals to reduce their health risks.
The government claims that analysis of ‘the drivers of preventable chronic disease demonstrates that a small number of modifiable risk factors are responsible for the greatest share of the burden’. The behavioural risk factors led by obesity, tobacco and alcohol apparently account for nearly one-third of Australia’s total burden of disease and injury. The chronic conditions for which some of these factors are implicated include heart disease, stroke, kidney disease, arthritis, osteoporosis, lung cancer, colorectal cancer, depression and oral health problems.
Since these risk factors stem from individual lifestyles it is obviously desirable for individuals to be aware of them. There may be a role for governments in provision of this information. Perhaps governments should also be involved in helping people in various ways to live more healthy lifestyles. It is questionable how far governments should go down this path, but it is difficult to object to modest efforts by governments to improve opportunities for people to live healthier lifestyles.
However, rather than helping people to help themselves the federal government has chosen the path of Skinnerian behaviour modification. It has chosen to drive changes in behaviour through what it describes as the ‘world’s strongest tobacco crackdown’. (This is one instance when I hope the government doesn’t actually mean what it says – some people in Bhutan have apparently been jailed recently for possession of more than small amounts of tobacco products.) The government’s strategy also involves ‘changing the culture of binge drinking’ and ‘tackling obesity’, but in this post I will focus on smoking.
Some of the tactics being used in the tobacco crackdown involve information and persuasion but there is also an element of punishment involved. The tobacco excise has been increased to over $10 for a packet of 30 cigarettes and legislation is proposed to require cigarettes to be sold in plain packaging. It seems to me that this amounts to persecution of smokers and their families. It will reduce the amount of household budgets available to be spent on other products and encourage some to avoid excise by obtaining tobacco from illegal sources.
As a former smoker, I am probably more strongly against smoking than most people who have never smoked. I encourage other people to quit smoking and discourage young people from taking up the habit. But having given up smoking several times, I know how hard this can be. Governments have no basis on which to judge that people are not in their right mind if they consider that the pleasures they might obtain from additional years of life are not worth the pain of giving up smoking.
In my view this question of whether smokers are capable of judging what is in their own best interests is at the crux of the matter. The politicians and bureaucrats who seek to modify the behaviour of smokers may see themselves as enhancing the capability of these people to have lives that they ‘have reason to value’, in accordance with well-being criteria proposed by Amartya Sen. If so, their attitudes highlight a major problem with Sen’s approach. Governments have no business deciding what kinds of lives individuals have reason to value.
Enrolling into a drug rehab program can be the hardest thing to do but it can save a life.
The government might as well argue that, since handicapped people can crawl on all fours or ask for help from strangers, there's no need to make buildings wheelchair accessible, the court said.Justice delayed is justice denied; get to stepping, Mr. Snow!
Three fiscal quarters into my new role at work I am pleasantly surprised to discover that CDHPs have quietly evolved from a disingenuous cost-sharing scheme foisted on workers by employers (see the Pollyannaish video, below) to a proactive, multifaceted approach intended to achieve “a pluralistic system that empowers patients and demands accountability from individuals and the health system, while adequately supporting the needs of the disadvantaged.”
Moreover, the criteria for determining whether or not these lofty goals are met are both simple and progressive:
Granted, the above is only Wye River Group’s take on the matter, but given that it comes directly from their An Employers’ Guide to Healthcare Consumerism which was published in 2006 I am inclined to take them at their word and note this as a sea change in suppliers’ attitudes towards the healthcare crisis in this country.
What Wye River Group refers to as healthcare consumerism is a synthesis of old and new ideas as well as delivery and payment models in the healthcare market. It encompasses consumer-driven health plans, value-based benefit design techniques, and good old-fashioned managed care (as opposed to managed access and/or managed costs).
Despite its name, healthcare consumerism isn’t mutually exclusive of government involvement. Indeed, the techniques it espouses could go a long way towards making the already superior healthcare model in place for US military veterans that much more cost-effective and efficient – not to mention portable to state and local governments and private industry.
There are few people as skeptical of for-profit payers as I am, but in light of this evolution of thought in the consumer-driven healthcare space I am open to – and hopeful at the prospect of being – proven wrong.
Hi Jeff,Here's the photograph in question:
I am delighted to let you know that your submitted photo
has been selected for inclusion in the newly released
second edition of our Schmap Northwest Guide:
If you like the guide and have a website, blog or personal
page, then please also check out the customizable
widgetized versions of our Schmap Northwest Guide, complete
with your published photo:
Thanks so much for letting us include your photo - please
enjoy the guide!
Managing Editor, Schmap Guides
It ain't so.
Every first-year high school debate student learns about fallacious arguments. It's a requirement and something you had better learn well unless you want your argument to fail, your proposal to lose, and what little social standing there is to be had from membership on the debate team to be negated by having your ass publicly handed to you by an even bigger geek at a public (albeit most likely unattended) public event.
I speak from experience here.
As the saying goes, things change.
In our modern era of corporate media, where a powerful and wealthy few dictate what constitutes both entertainment and news, as well as their bastard offspring - infotainment, the validity and coherence of one's argument doesn't matter; volume does.
Volume can be measured in decibels (talk radio), eyeballs (Drudge Report), Nielsen Ratings (Fox News, Desperate Housewives), circulation (The National Enquirer), or some combination thereof. Health Care News apparently knows how to pump-up the volume: according to their masthead they reach 53% of all healthcare professionals.
I know that healthcare is a business, and that even the most selfless non-profit organization has to figure the bottom line into the equation somewhere, but it is my sincere hope that when most healthcare professionals and the organizations they work for need to get a feel for the pulse of the nation on important questions of the day, they'll keep in mind that Charmin is a better quality paper than The Heartland Institute's propaganda organ is.
Why am I being so hard on Health Care News? For starters, they have a widget on their site that is a consistent part of their navigational structure that declares Crichton is Right! This is a reference to science fiction author and 2006 American Association of Petroleum Geologists Journalism Award-winner Michael Crichton, whose novel State of Fear denies the science of the greenhouse effect and slanders The New Republic Senior Editor Michael Crowley.
With both John McCain and Barack Obama in favor of joining some version of the Kyoto Protocols and enacting some sort of carbon cap-and-trade system, this ranks The Heartland Institute right up there with holocaust deniers and The Flat Earth Society in my book.
Is this unfair of me? Am I painting with an overly broad brush? Am I resorting to unjustified Ad Hominem attacks and throwing the baby out with the bathwater just because I think Michael Crichton is a despicable human being and corporate drama whore who is trading on name recognition in lieu of long-since-gone talent?
I don't think so.
Here's a critique of their three-article, red-letter Single-Payer expose'.
Better yet, read the original articles independently of my critiques, and decide for yourself.
Meanwhile, I will be tackling all three of Health Care News' extremely fallacious and biased articles one-at-a-time over three posts. First up:
This article attempts to paint a picture of what universal healthcare in the United States will look like by describing in lurid detail what's going on at the bottom of the barrel in Russia's healthcare system.
For this article alone, the fallacies include:
Many state-run hospitals, particularly in remote areas, do not have hot water, and some do not have running water at all. Even the most basic medicines are often in limited supply.This is an attempt to form a Post Hoc fallacious argument. It fails in this regard, however. Awful Facilities actually Confuses Causes and Effect - the Russian Federation is the successor to the collapsed Soviet Union and the product of more than a decade of economic decline before its recent economic stabilization. Consequently, it's healthcare infrastructure isn't a shambles because the country's national, single-payer healthcare model is a failure; the country's national, single-payer healthcare model is a failure because the country's healthcare infrastructure is a shambles!
Healthcare is far too important to leave to politicians - be the autocrats or Democrats [sic]," said John R. Graham, director of health care studies at the Pacific Research Institute.Did you spot the Ad Hominem fallacy? It's tricky because it's also an example of Guilt by Association. In the above statement, the poor state of the Russian healthcare system is the fault of the autocrats, who are synonymous with Democrats! Since all Democrats are autocrats, and autocrats can't be trusted to administer healthcare, then obviously neither can the Democrats.
"The Russian 'free healthcare for all' system is nothing of the sort," said Jeff Emanuel, research fellow for healthcare policy at The Heartland Institute and managing editor of health Care News. "Instead, it is simply another program built on governmental taking of taxpayer fund and mismanagement of the services it promises to provide."You see, in the neoconservative fantasy land that Jeff Emanuel lives in, any single failed government program from any government anywhere is proof that all government programs from all governments everywhere will fail! And be sure to take a good look at just who Jeff Emanuel is: the editor of the very publication the article appears in! While this isn't a logical fallacy, it certainly makes him a less than objective - and therefore credible - subject matter expert for this particular piece.
Despite the fact that there is currently no legislation before Congress to institute a national, single-payer healthcare system, nor a presidential candidate from either party intending to introduce one (a Factual Error), even if universal coverage and a national, single-payer system were the same thing (which they are not), citing only Russia as a representative example of such a system is not only a Biased Sample fallacy, it also grossly distorts the success of the many other national, single-payer healthcare plans of every other industrialized country, all of whose citizens enjoy a comparable or superior degree of health and wellness than the average American does from healthcare systems that universally consume fewer resources and produce comparable or superior outcomes to our own.
(It is also insulting to the intelligence of anyone who has been paying attention since 1991 and knows that for all of our problems, the United States and the keystone republic of the former U.S.S.R. have about as much in common as William McGuire and Mother Theresa when it comes to infrastructure and other assets to bring to bear on their respective national healthcare concerns!)
In fact, according to the CIA World Factbook, as of 2007, per capita GDP in the Russian Federation was $14,600 - less than .33% (one-third) of per capital GDP in the United States of American ($46,000) during the same period!
Despite the enormous differences between the two counties, the average life expectancy at birth for all Russians is 84.5% that of their American counterparts, a difference of only 15.5%. Based on these numbers, if the United States were to adopt the horrific Russian healthcare system in its current form in its entirety tomorrow, but maintain current U.S. healthcare spending levels, median life expectancy at birth for all Americans would exceed 129 years!
|Life Expectancy at Birth||Russian Federation||United States of America|
Now, I know that this is a Misleadingly Vivid example, but then again so is Health Care News' representation of the Russian healthcare system as a legitimate cautionary tale for healthcare reformers in the United States looking to implement some form of universal coverage or otherwise assure care is made available to nearly 50 million of their fellow uninsured citizens.As I pointed-out above, Rina Shah bases her entire article on a Factual Error when she presents the situation in Russia as an example of a failed universal healthcare system. However , Russia's implementation of universal healthcare is a national, single-payer universal healthcare system; there are no proposals for implementing such a system in the United States from either political party or presidential candidate.
Research conducted by Moscow's INDEM think tank in 2004 showed Russians spent some $600 million each year on under-the-counter payments to health care providers. The Russian Academy of Sciences' Open Health Institute more recently estimated rampant corruption siphons off as much as 35 percent of the money spent on health care nationwide annually.Do you see the Strawman here? The figures presented above only proves that Russia's healthcare market is inadequately policed; it doesn't prove that universal or single-payer healthcare systems are inherently corrupt or result in substandard wages for healthcare professionals. The average pay of Russian healthcare professionals is also something a Red Herring: compensation of individual healthcare practitioners is not an indicator of the likelihood of an overall healthcare market's ability to function efficiently, as the performance of healthcare markets from Canada to Cuba clearly show.
Low wages are another problem. Yearly salaries of physicians average $5,160 to $6,120, while nurses average $2,760 to $3,780. This often results in underpaid physicians accepting bribes for higher-quality care.
Reforms drafted this spring by the Russian Federal Assembly include placing higher emphasis on primary care, shutting down numerous substandard hospitals, scaling down the scope of free medical assistance guaranteed by the state, and increasing physician salaries by reimbursing doctors according to the number of individual treatments given instead of by the number of hours worked.Do you see what's going on here? The reforms proposed by the Russian government are never addressed. Instead, they are summarily dismissed.
"Instead of forcing people to pay into this failed program, Russia's government should allow the market to influence the health care system, which it can begin to do by allowing its citizens to choose how their own health care money is spent," Emanuel said.
So-called "universal" health care does not actually exist, says Graham.
"At best, in a functioning democracy like Canada or Britain, it results in unequal access to health care by government rationing, lack of investment in innovation, and shortage of medical professionals," Graham pointed out. "At worst, in a country with little democratic bona fides, it results in the situation we are seeing in Russia."The author has taken great pains to paint an unfavorable, ugly, and frankly prurient (from a healthcare policy perspective) picture of Russia's national, single-payer healthcare system. Having savaged the concept generally (i.e.: Poisoned the Well), Rina Shah sees no reason to bother backing up the claims made in the concluding paragraph about the failings of universal healthcare systems in functional democracies, which are better and more realistic models for potential universal healthcare solutions in the United States. Which was clearly her intention all along.