Wednesday, January 20, 2010

The Massachusetts Aftermath

With the stunning election of the Republican Scott Brown from Massachusetts last evening, the pundits are awash in analysis and retrospection. The forces that aligned to elect a Republican to the "people's seat" in Massachusetts are too numerous to expand upon here. Not being from Massachusetts, it would be presumptuous of me to claim I understand all of the issues at stake. I am simply not a political pundit.

But from a 50,000 foot perspective, I am amazed that the Commonwealth of Massachusetts, long the shining star upon which our national health care reform efforts were modeled, has effectively stalled (stopped?) the partisan railroading of the current health care legislation hashed out for months in both houses of Congress. Do they know something about their health care program that the rest of the nation doesn't? The economy? The costs involved? The lack of representation "at the table?" Tough to know. Maybe it was all of these things and more.

But irrespective of the outcome, our country must reconsider the obvious: we have to do something to fix our health care crisis in America. We should not and simply cannot gloat over the victory. Too much is at stake. The reality is that many people simply cannot afford health care any longer. Many have no means to obtain insurance. Many, many people are unemployed and likely to stay that way for some time, yet their health care needs continue.

So what to do now.

Here are some thoughts (and I'd welcome others thoughtful perspectives).

First, this debate cannot occur behind closed doors. I find it ironic that the very President who campaigned and fund-raised with almost uncanny use of the internet's reach, later decided to go underground with the late-stage health care negotiations securing deals for a cornucopia of interests behind closed doors. When the deals were exposed, most of America realized they'd been hoodwinked at great cost to themselves. Americans don't tolerate that for long. Especially in the era of the internet. Televise the negotiations on C-SPAN. Open the debate up. Clarify what's needed. Make the people the concern, not insurers, pharmaceutical companies, and hospital systems.

Second, limit the scope of the legislation. Define where the priorities lie first. If the real need is "insurance reform" rather than "health care reform," then limit the legislation to that endeavor. Open up the market across state lines. Give people options. There is no questions that the tentacles of health care reach many different constituents, but attempting to change such a significant portion of our economy all at once seems counterproductive.

Third, doctors and their patients need to continue to take a more active role in the process. Health care is becoming more like the internet: better communication between providers and patients is becoming the norm. Legislators better learn this, for doctors and patients will insist on understanding how any piece of legislation will affect their interactions and access. We are the foot soldiers of health care and in that way, the legislature would be well advised to support the troops first.



Keith said...

People seem to talk in generalities about this legislation which makes it difficult to know what changes they would concretely propose.

My take is that there were three objectives to the legislation; 1)to correct some of the abuses of the insurance industry in respect to existing medical conditions and what many perceive as attempts to price sick people out of their insurance coverage after they have falleen ill. 2)To try to contain the growth of health care costs. 3) To broaden the market to include the increasing number of individuals that simply cannot afford health insurance, even if it is availible.

You could certainly put constraints on the insurance industry in regards to preexisting conditions, but how do you propose to get middle class people health insurance without the subsidies in the current legislation? Or are we simply going to continue to build a two tier health system where we have gleeming new academic hospitals that cater to the insured and underfinanced hospitals that will take care of all those who cannot afford health insurance?

To your one tangible idea of allowing health insurance companies to sell accross state lines, I have yet to see anyone explain to me how this would lower health insurance costs! Markets become dominated by a single insurer because as that insurer gets bigger, it can extract the best deal from providers since it services the most patients. In the Chicago area, providers have limmited bargaining power with Blue Cross since it covers half the private insureds in Chicago. Other insurers are already attempting to compete, and they all have small slivers of this market. Unicare recently pulled out of the market altogether, so if a big insurer like Unicare can't make a go, who else out there is going to challenge the Blues? If you allow insurers to sell accross state lines, how will they build a competitve network for services in Chicago that will be less expensive than the Blues? It is much easier for providers to simply decline to contract with an insurance company with a limited number of covered lives, so the smaller insurer need to pay more to obtain the service contracts they need. The fact of the matter is that there are huge barriers to competition in term of a new company entering the market that stifle competition, and allowing insurance sales accross state lines will do nothing to solve this problem.

Finally, what in insurance regulation would slow the costs of health care inflation? Nothing you propose would stop the incessant climb of health care costs.

As Obama has said, if we do not stop the steady climb of health care costs, then Medicare, state, and local costs will eventually consume our geovermental budgets. And you can bet as the costs climb, more people will turn to federal, county, and state subsidized health assistance which will eventually overwhelm the system.

We need a comprehensive bill that deals with all these issues; not simply insurance reform.

DrWes said...


You missed the first and most important point: transparency.

If we don't begin to have tranparency of costs involved with every aspect of health care delivery in America and consumers don't know how much anything costs in our system, how can we even begin to have a discussion about where cuts to costs can be made?

Also, remove the employer from the health care equation (hell, some would say 10-17% of employable Americans are out of work now, anyway, and few individuals outside the government can plan on a consistent employer the rest of their working years).

I'll even give you that some individuals are going to need subsidies. We know this. But in order to make ANY plan sustainable, we better have a real idea about costs first, not some pie-in-the-sky 10-year estimate from the CBO. Did the CBO's estimates include the costs of our current hospital construction projects and the political handouts to Louisiana and Nebraska?

Didn't think so.

CriticalCareRN said...

It seems to me that people often use the term "cost" when the real idea is "spending". While I think both need to be addressed in reform, it seems like too often people say "cost" when they really mean "spending".

For example, can anybody explain to me how tort reform in Texas caused "costs" to rise rather than "spending". Post tort reform, the state saw a huge influx of new physicians opening up practices in areas that previously did not have local services. When you look at Texas pre tort reform, they spent "x" percent of GDP per capita. Post reform the "x" percent of GDP per capita increased - and people point to that and say, "see tort reform did not bring down costs". Is the rise in the percent of GDP per capita not from spending more on health care because of increased access? Is their higher spending in Medicare because of higher "costs", or because of higher "spending" due to increased access? Can somebody definitively prove that access to services is a bad thing for citizens, except for the fact that it consumes money?

This, of course, brings on a question that has lingered with me throughout this entire debate. So many people are angry that too many people do not have adequate access to the system - yet somehow believe that those people gaining access will not impact that frightful number of $2.3 trillion on health care. How is this possible?

The CBO itself has reported that increasing primary care will cost money, before it saves money, for a long while to come.

Moreover, it seems to me we should be looking more closely at France for their private health insurance industry practices. Perhaps they have some things we could adopt. After all, that system ranked number 1 on the much touted WHO health care systems report - and, interestingly, they are not single payer and have a vibrant private insurance industry. They DO have large problems too and many things there would not translate well here, but they also have a vibrant private health insurance industry, universal coverage, and low administrative costs (not to mention a well controlled tort system).

Anonymous said...

I can't explain why Scott Brown won so decisively here in Mass., but I can tell you that after his victory he commented that we don't need that health care bill here because over 90% of Mass. residents are already insured. He failed to mention the recent drastic jump in cost for those of us who have to buy our health insurance through the Commonwealth Connector. That's the kind of short-sightedness the rest of you can expect from our junior senator.

CriticalCareRN said...

I do agree that there are things we need to change to keep over-consumption, and unnecessary consumption, from being such a problem.

But the thing that boggles me the most is that when we compare how much we "spend", not to mention our higher costs, with every other nation around the world, we must compare these things as well:

- National obesity rates (Not only do overweight and obese people NEED to consume more health care, but they consume more and still are no healthier - because the "cure" lies more in their possession than it does with the health care system).

link: (

- Alcohol, tobacco, heroin, cocaine consumption. According to WHO in 2008, the US is the largest consumer of those things too - which wreak havoc on the human body leading to more consumption, lower life spans despite that consumption, and less healthier lives despite that consumption.


- Auto accident rates. Again, we lead the world in this.

link: (

Compare patient non-compliance rates

Compare costs for employing multiple language interpreters.

Compare citizen ethnic diversity, challenging health care plans with multiple genetic and cultural diversities.

Compare malpractice costs. While we are the only industrialized nation without universal coverage, we are also the only industrialized nation without a controlled tort system.

Compare costs for treating illegal immigrants.

Compare costs for drugs and medical equipment/devices.

Compare costs for unions imposing unreasonable demands on hospitals.

Compare costs for education/training of nurses, tech and doctors.

Compare plastic surgery consumption. While much of this is out of pocket spending, it can also have bad outcomes putting people in ICU, rehab, etc.

Link: (

Compare teen pregnancy rates

Link: (

Compare child maltreatment

Link: (

Compare gun violence rates.

Link: (

Compare rape rates

Link: (

Compare total crimes

Link: (

I am sure there are more, but these are a few.

Andrew_M_Garland said...

The problems in health care have accumulated over time in response to bad government policy, and it is a mistake to attempt a "comprehensive reform" by applying three times the government policy to supposedly fix it.

High cost is the problem that most people care about. It is unlikely that doctors "overcharge" more than other professionals. People observe that simple medical services incur a high bill, and they don't like it. Their insurance may pay for the $10 aspirin in the emergency department, but this communicates (correctly or not) that the medical "system" is ready to overcharge their insurance company. People see the aspirin and conclude that doctors and hospitals are overcharging. They want government to step in and stop this.

Ironically, the government is causing this situation in the first place. A few of the more serious problems should be fixed, then the situation should be reviewed.

The general answer is to allow doctors and hospitals to form their own groups and standards. Allow great freedom to the people who know the most about medicine; let hospitals and doctors solve medical problems and set standards. Remove the need for control by the people who know the most about dealing with government.

The Political Distribution of Wheat

The above is a short analogy to what is happening in the market for medical services. What does a market for wheat have to do with healthcare? It is easier to understand.

I'm not in the medical business; the following is from thought and reading. If I am wrong, I am open to being set right.

() Hospitals are required to deliver free medical care through their emergency departments, at the same level of care as those who pay. Hospitals cover the extra costs by raising prices until the "rich" insured patients are paying enough to cover the non-paying patients. This is a big and hidden tax on medical care, passed along to the insurance companies, and so to anyone buying insurance.

Hospitals do this because: They can; They have no choice; and They see their role as treating everyone. They are caught in the middle of government requirements. Some hospitals and emergency departments have closed under this financial starvation, exactly the ones providing the most care through their emergency departments.

Answer: If the government wants to provide care, then it should pay the hospitals the market rate and collect the costs as general taxes, not as hidden taxes on insurance.

() Doctors and hospitals are pressured by the government into accepting 60% of usual fees for Medicare and Medicaid patients. These costs have to be recovered from paying patients, as in the situation above for the emergency department. Again, prices go up for those who can pay, to cover the unpaid costs. Some hospitals have closed under this financial starvation, exactly the ones providing the most care to Medicare/Medicaid patients.

Answer: If the government wants to provide care, then it should pay doctors and hospitals the market rate and collect the costs as general taxes, not as hidden taxes on non Medicare/Medicaid patients.

Andrew_M_Garland said...

() States regulate health insurance companies in detail. This political control has led to deals with insurance companies, medical suppliers, and particular provider groups. This increases medical costs and the cost of insurance. All insurers in a state must cover the same things, removing price competition.
-- Insurance companies bargain to be one of a few favored providers within each state.
-- Providers of such as Acupuncture, Massage, Chiropractic, Health clubs, and Nutritional Counseling arrange for their services to be provided free under regulated health insurance.

Answer: Let insurance companies include or not include such services according to individual choice and a fee schedule.

() An effort to get around World War II wage controls still affects us. Companies can provide health insurance to an employee as a part of salary that is not taxed. That part of salary would be taxed if paid out, so that the employee could buy his own insurance. This puts companies in the middle, with many bad effects.
-- Insurance changes with a person's employer and the person's ability to work.
-- The employer chooses the insurance.
-- The individual purchaser is a neglected part of the market.
-- The market is not addressed toward individual choice.
-- Policies are not designed to stay with the person, so they are not arranged to be transferrable between insurance companies or states.

Answer: Make all health insurance tax deductible, and make company provided insurance optional.

() Doctors practice defensive medicine to prevent lawsuits that take their time and threaten their careers. This drives costs up.

Answer: Create Medical Courts to make decisions based on science and good practice, with some standard for cost per life saved. Doctors should be able to inform patients about the tests and procedures that could be done at the patient's extra expense, if he wants the extra assurance. Establish reasonable awards and penalties for malpractice.

() Rules over doctors and hospitals have become more bureaucratic, detailed, and paper-based. Doctors do much work recording what they have done, mostly to meet these rules, with little indication that this actually improves outcomes.

Government agencies have applied these rules, in part and perversely, as a way to not pay for some medical care ("never events"). This produces Byzantine responses and raises costs. Worse, this prevents hospitals and doctors from working in more efficient, unconventional ways, because these don't fit the rules in place.

The rules for payment are particularly strange. Doctors are paid for office visits and procedures, but not for phone consultations that are often as effective and more efficient. Medical liability also directs doctors to physically see patients more than the doctor might judge necessary.

Answer: Let hospital associations or regional groups set reasonable practices and standards, not government agencies.

() State and city regulation sometimes prevents inexpensive delivery of care. For example, walk-in clinics are prohibited in Boston because the mayor doesn't like them.

Answer: Let hospital associations or regional groups set reasonable practices and standards, not government agencies.

DrWes said...


Your point on what is "spent" vs. "costs" is important. Thanks. But the "costs" should be made to come in line with what is "spent," in my view.

Case in point: Today, I had a patient describe how he was charged a fairly high amount from one hospital system for a Holter monitor. He was surprised at the "charge" (or "cost" as it may be). He called a competing hospital system to see what their charge was. It was $300 dollars cheaper. When he called his "cadillac" insurer to ask why they were paying the higher amount, he was told that his co-pay would remain the same, irrespective of the charge. (Why quibble, right?) But he quibbled and was later refunded $250 of his deducible because of his efforts.

When patients are empowered with price comparisons, the market has to adapt to these pressures. If insurers are reaping the extra hidden "spending" from the inflated "costs" that they have negotiated with a hospital system, then no wonder we have a problem.

Transparency of prices and forcing costs to align with the amounts "spent" would greatly help to correct this extra hidden windfall for insurers and hospital systems at no added cost to the patient or our health care system.

Keith said...


What transparency do you want? The health care legislation is posted on line for all to read!
We know the deals that have been done to garner the last votes. I can't disagree that it would be nice to have some idea of costs within the health care system, but we are not talking in this legislation at this stage about cost cutting measures (the cardiology cuts and elimination of consultation codes have nothing to do with the legislative package). We are talking about practical ways to insure a greater portion of our population and bring payment reform that is driven by quality rather than quantity. The legislation is what it is; the question is not the process of its attainment, but what you see as the deficiencies with it.

After all, what legislation gets produced with 100% transparency?

DrWes said...


We are talking about practical ways to insure a greater portion of our population and bring payment reform that is driven by quality rather than quantity.

Insuring a greater portion of our population is fine, but I fail to see where quality will not be affected when we plan to insure those people by also cutting $500 billion from our current Medicare budget.

That's nothing more than fantasy thinking and that's the problem with the current legislation. People aren't blind to this reality.

Keith said...


I don't know. Seems like there is alot of waste in the Meidcare program. And as I keep teling you, the rest of the civilized qorld seems to get better health results than us for half the cost.

At any rate, how would transparency solve this argument and how would this so called transparency manifest itself?

DrWes said...


" would transparency solve this argument and how would this so called transparency manifest itself?

When I speak of transparency, I am not speaking of transparency of the legislation (even though this, too, is nearly impossible to comprehend as a single paragraph of the legislation weaves its way through Social Security laws, IRS statutes, and a slew of other agencies in its quest to "improve" health care), instead I speak primarily of price transparency for all things medical. How would that look?

Lots of different ways.

For instance, we're spending $19billion in seed money to get health care IT off the ground, right? Prices for tests should be displayed when doctors enter orders. Maybe we'd think twice about ordering daily CBC's, CXR's, etc. This should be easy enough to implement.

Another idea: No "retail price" markup for the uninsured vs. a separate cheaper price for the insured. Make it a "Car-X no-haggle pricing" structure - what you see is what you get - then require all health care services for each institution to be published online. While I appreciate that hospitals must place a markup on devices, etc. to pay for their overhead, wouldn't it be real change if hospital systems had to choose the prices they think were fair for servces delivered and offer the same published prices to ALL patients? Then hospital systems could compete between themselves for business. This would be a game-changer.

Do the same for insurance prices, drug prices, medical devices, etc. etc. What is published is what you're charged. No exceptions. No special deals.

Another idea: Ideally, I'd bag direct-to-consumer advertising if I could. The US and New Zealand are the only two countries in the world that permit this. But if we insist in allowing drug companies to keep doing direct-to-consumer ads on radio and TV, then also insist they have a "Surgeon General's warning" that discloses how much the drug company paid for EACH advertisement included in the message for all to hear. Heck, if they can include every side effect, why not how much money they've spent for air time and for the production of the commercial? Maybe people would wake up to how this adds to drug costs.

I know, I know - pipe dreams, right? Perhaps. But I believe that if legislators can change rules on how they pay doctors and nurses at the blink of an eye, there's no reason they couldn't implement any of these reasonable measures to facilitate lowering costs in healthcare if they really wanted to.

Problem is, it appears to this observer that most of the "players" just want to limit any real change that might affect them, rather than working for what is most likely to permit sustainable cost control in the name of protecting people's health.

Bottom line: there are TONS of ways to save costs but very few who appear they could make it happen.

Gosh - all this even before tort reform....

Keith said...

Now I get it!

You want transparency of costs; not transparency in the political process. All sounds good to me. Can't find anything out regarding costs in most instances until you get the insurance claim form, which is after the fact.

But alot of health care is not subject to cost comparisons even in the best of situations. It would help in some respects, but once patients are acutly sick, I don't think there is much choice in their options. When I have a patient that is bradycardic, I can't shop around for the best price for there pacemaker insertion, and most patients probably would not apprciate me selecting the least expensive option for them. So what's the point?