November 1, 2012
Confusion
"There’s too much confusion,
I can’t get no relief."
These lyrics, sung by Jimmy Hendrix in his famous song All Along the Watchtower, can be used to describe the present state of organized Medicine concerning quality indicators. For almost two decades, there has been a movement toward a uniform set of practice guidelines which would elevate the quality of care delivered to the American public. Practice Guidelines, Evidence-Based Medicine and Comparative Effectiveness are just three of the buzzwords used by the groups promulgating these movements.
Medicare has set a number of quality indicators, which they measure accurately, as indicators of how well a practice or an institution is performing in delivering quality healthcare. The problem has become that many of these quality indicators are falling by the wayside. The latest to go is the quality indicator which measures how often Beta Blockers are prescribed after myocardial infarction (heart attack). Beta Blockers were believed to significantly reduce the incidence of second heart attack over the long run. A recent long-term study, published in the Journal of the American Medical Association, seems to have disproved the value of Beta Blockers in this setting.
This is not the first, nor will it be the last, quality indicator to have….well….quality issues. Inhaled steroids for asthma have been questioned. Hormone replacement for women has certainly fallen aside; in fact, the incidence of Breast Cancer in the USA has fallen by 15% since hormone replacement therapy, once a leading quality indicator, was exposed as harmful 10 years ago. Yearly mammography, once a solid quality indicator, has been under fire recently, both scientifically as well as politically. Yearly PSA, another quality indicator, has been shown to be more harmful than helpful. Colonoscopy every five years as opposed to every ten years is another.
As we look to get more bang for our buck from our healthcare dollars, it appears that what we consider to be quality is somewhat elusive. One can make the argument that Medicine is an evolving science and as such will have forward movement as well as setbacks. The bigger question is why is so much of Medical Research so wrong? Conflict of interest, career advancement, income, regression to the mean and bad public policy are a few of the short answers.
The present crisis in Medicine revolves around how little real good we get from all the money that we throw at it. Until we reform how medical research and progress are actually carried out, the course to bad outcomes and bankruptcy will continue to be paved with the best of intentions.
April 16, 2012
Back Door Single Payer
The Supreme Court will be deciding on the Constitutionality of Obamacare in June. Pundits are already proclaiming victory for the right who has fought this legislation tooth and nail. While most agree that the individual mandate will be struck down, few agree that the entire bill will be swept aside. For one thing, the justices did not want to do the work of reading the entire document; who can blame them since few in the House or the Senate read the entire bill either. The Court is also concerned about its legacy (as too activist) if they send the entire bill into the dumpster.
If they strike down the individual mandate only, this will eventually end up as a victory for the far left. Yes...you heard me.... a victory for the far left. The far left wants a single payer system as the ultimate goal; think of it as Medicare for all from birth to death. They may have to wait a while and they may have to deal with a few speed bumps, but the elimination of the individual mandate is the first step toward that ultimate goal. If the remainder of the bill is preserved, the insurance companies will be left saddled with all sorts of expensive new regulations which will eventually destroy their current business model. Chief among those is the elimination of the pre-existing condition problem. Under the new paradigm, people with no insurance (or lousy insurance) can buy gold-plated insurance AFTER they are diagnosed with a serious medical condition. This is akin to buying collision insurance after you have had your auto accident. Under the original bill, the individual mandate would have covered the cost of eliminating the pre-existing condition dilemma. With the individual mandate toast, the economics of eliminating the pre-existing condition problem do not work.
The new bill also calls for a massive expansion of Medicaid by about 40%. Medicaid (Medicare's ugly sister) is a shared federal/state program which provides medical care for the poor. Under the new bill, it will also serve much of the middle class. Medicaid is a low cost, low quality, least common denominator form of health care; it contributes mightily to America's low quality world ranking of medical care delivered. Much of Medicaid's budget goes to ancillary health care matters (Nursing homes, transportation etc.) as opposed to direct medical care.
Stuck with all these new unfunded liabilities, the big insurance companies will put a bigger squeeze on hospital and other providers and further ratchet down their medical payments. This will force many hospitals and providers into bankruptcy (or at least, have a very significant impact on the quality of the care that can be delivered.) Many insurance companies will quickly pivot into models that cherry pick only the profitable segments of the entire apple or abandon medical insurance models altogether.
As this evolves over the next 3-10 years, the government will incrementally continue to expand Medicaid deeper and deeper into the middle class until almost all Americans have either Medicaid or Medicare as their only available coverage. Of course, the top 5% will continue to have private insurance because they will be the only one's who can afford it. Medicare and Medicaid will, at some point, merge and become one entity.... probably Medicare. The end result will be that we will have a single payer for 95% of the population. Isn't this the system Great Britain has right now? The National Health Service covers about 95% of the population with the other 5% covered privately. As George Orwell famously said in Animal Farm: "All animals are equal but some animals are more equal than others."
So, as the right savors its victory upon the striking down of the individual mandate, the left will be sitting pretty with its ultimate dream of a single payer. It makes you wonder if the Obama administration threw the case.
December 18, 2011
Confusion is King
In philosophy, Dualism is the concept where opposing forces battle each other for supremacy: yin vs. yang; liberal vs. conservative; state's rights vs. federal rights; good vs. evil. Hegal, my favorite philosopher, carried this concept a bit further with his political/philosophical idea of dialectics; the central concept is the thesis which is balanced by the opposing view, the antithesis. These opposing views are resolved by the synthesis whereby the two opposing views reach a settlement and move on to the next level.
The upcoming presidential election is about the economy; as Bill Clinton famously remarked on his way to the White House: "It's the economy, stupid." For at least 75 years, the dualism of the two major political parties has orbited the political-economic philosophies of two major competing economists: John Maynard Keynes and Friedrich von Hayek. Keynes, the brilliant Englishman, is the grandfather of Keynesian Economics and the first economist to describe macroeconomics (the overall picture vs. microeconomics, the building blocks of any economy). Keynesianism proposes some degree of government central planning, a large degree of government intervention during recessions (as a bridge to returning prosperity), and strong manipulations of both monetary (interest rates and money supply) and fiscal (government spending and taxation) policies to guide the economy to ever more sustainable levels of progress. Hegal would call this the thesis.
The antithesis of this school of thought is the political-economic philosophy of Hayek, the best known member of the Austrian School of Economics. In his most famous work--The Road to Serfdom-- Hayek condemns central planning, big government, deficit spending, excessive regulation and the nanny state.
It would be a simplification to state that the Republicans embrace Hayek, while the democrats embrace Keynes as their respective mentors. If it were that simple, the thesis and the antithesis would reach Hegelian synthesis (dialectics); some compromise of the two schools would prevail and the country could move onto a higher plain of function until the next crisis appears. Why is this not possible (and certainly not happening)?
It is not happening because although one party or the other may talk the talk, they are most definitely not walking the walk. Ronald Reagean, who one would on first glance identify with Hayek, raised the deficit to record levels and although best remembered for his tax cuts, also raised taxes significantly at the end of his second term. George H. W. Bush, who famously said: "Read my lips, no new taxes", went on to raise the deficits even further and reversed course to increase taxes as well. Bill Clinton, who was pegged as a tax and spend Democrat surprised many when he cut entitlements, balanced the budget and reduced regulation. George W. Bush, who ran, like Reagan, on reducing the role of Government in our lives, played a major role in one of the biggest increases in entitlements in modern history--Medicare Part D--and increased the deficits to record levels each of his 8 years in office. He also turned positively Keynesian when he helped shepherd an $800 billion dollar stimulus package into law during the recent economic meltdown. He claimed to have Hayek as one of his favorite mentors, but turned positively Keynesian when things got crunchy. Obama so far has been truly Keynesian since he took office but it is early to see how he will finish up.
Voters are confused. The candidates claim to identify with one school or the other as their respective parties do....but then they do just the opposite. Reagan and both Bushes were hardly fiscally responsible. Clinton was hardly Keynesian.
What is really going on here is that the political establishment has become increasingly a textbook example of crony capitalism. Each party has its respective special interests to pay back for helping to get them elected. As they say in Texas..."You dance with the them that brung ya". As a voter, you can no longer vote for a republican because you want fiscal responsibility, lower taxes and less regulation. As a democrat, you can no longer vote for your candidate because you want secure entitlements, more regulation of Wall Street and a wider social net. As a voter, you need to look at what special interests are pulling the strings on the candidates and by extension, what agendas those special interest are trying to promote.
The political identities of Keynes and Hayek (thesis and antithesis) will not be reaching any synthesis in the near future. This is why we have political gridlock and why such a large proportion of the electorate is dispirited and depressed. This morass will continue until we discover a way to reduce the influence of special interests on our present day political sphere. As my father used to say: "We have the best Congress money can buy."
The upcoming presidential election is about the economy; as Bill Clinton famously remarked on his way to the White House: "It's the economy, stupid." For at least 75 years, the dualism of the two major political parties has orbited the political-economic philosophies of two major competing economists: John Maynard Keynes and Friedrich von Hayek. Keynes, the brilliant Englishman, is the grandfather of Keynesian Economics and the first economist to describe macroeconomics (the overall picture vs. microeconomics, the building blocks of any economy). Keynesianism proposes some degree of government central planning, a large degree of government intervention during recessions (as a bridge to returning prosperity), and strong manipulations of both monetary (interest rates and money supply) and fiscal (government spending and taxation) policies to guide the economy to ever more sustainable levels of progress. Hegal would call this the thesis.
The antithesis of this school of thought is the political-economic philosophy of Hayek, the best known member of the Austrian School of Economics. In his most famous work--The Road to Serfdom-- Hayek condemns central planning, big government, deficit spending, excessive regulation and the nanny state.
It would be a simplification to state that the Republicans embrace Hayek, while the democrats embrace Keynes as their respective mentors. If it were that simple, the thesis and the antithesis would reach Hegelian synthesis (dialectics); some compromise of the two schools would prevail and the country could move onto a higher plain of function until the next crisis appears. Why is this not possible (and certainly not happening)?
It is not happening because although one party or the other may talk the talk, they are most definitely not walking the walk. Ronald Reagean, who one would on first glance identify with Hayek, raised the deficit to record levels and although best remembered for his tax cuts, also raised taxes significantly at the end of his second term. George H. W. Bush, who famously said: "Read my lips, no new taxes", went on to raise the deficits even further and reversed course to increase taxes as well. Bill Clinton, who was pegged as a tax and spend Democrat surprised many when he cut entitlements, balanced the budget and reduced regulation. George W. Bush, who ran, like Reagan, on reducing the role of Government in our lives, played a major role in one of the biggest increases in entitlements in modern history--Medicare Part D--and increased the deficits to record levels each of his 8 years in office. He also turned positively Keynesian when he helped shepherd an $800 billion dollar stimulus package into law during the recent economic meltdown. He claimed to have Hayek as one of his favorite mentors, but turned positively Keynesian when things got crunchy. Obama so far has been truly Keynesian since he took office but it is early to see how he will finish up.
Voters are confused. The candidates claim to identify with one school or the other as their respective parties do....but then they do just the opposite. Reagan and both Bushes were hardly fiscally responsible. Clinton was hardly Keynesian.
What is really going on here is that the political establishment has become increasingly a textbook example of crony capitalism. Each party has its respective special interests to pay back for helping to get them elected. As they say in Texas..."You dance with the them that brung ya". As a voter, you can no longer vote for a republican because you want fiscal responsibility, lower taxes and less regulation. As a democrat, you can no longer vote for your candidate because you want secure entitlements, more regulation of Wall Street and a wider social net. As a voter, you need to look at what special interests are pulling the strings on the candidates and by extension, what agendas those special interest are trying to promote.
The political identities of Keynes and Hayek (thesis and antithesis) will not be reaching any synthesis in the near future. This is why we have political gridlock and why such a large proportion of the electorate is dispirited and depressed. This morass will continue until we discover a way to reduce the influence of special interests on our present day political sphere. As my father used to say: "We have the best Congress money can buy."
March 24, 2011
Contradictions
Obamacare appears to be heading to the Supreme Court for a showdown. Multiple federal judges in multiple districts have either ruled that parts of the legislation are unconstitutional or have ruled that they are constitutional. Many are calling for an expedited course--skipping the Appeals Court level--and going straight to the Supremes. Their arguments are persuasive.
The short version is the question: does the Congress have the right, under the commerce clause of the constitution, to force citizens to buy health insurance. This is called the individual mandate. The secondary question is: if the individual mandate is unconstitutional, is the whole bill unconstitutional?
I am no legal scholar and will make no predictions about how this will turn out...however, I recall the philosopher, social scientist, political scientist and trouble maker Hegal, who famously suggested that the argument that has the fewest internal contradictions should prevail. Following that logic, I would like to know that if the Supreme Court finds that Congress cannot compel citizens to buy health insurance, can hospitals and physicians and other providers begin to refuse to treat people who have no insurance and who refuse (or are unable) to pay? Decades ago, it became illegal for any health care facility to refuse treatment based on his or her ability to pay. Then the infamous HIPPA legislation made it illegal to even ASK patients in the emergency room if they had insurance before they underwent at least an initial medical evaluation. Health Care facilities have been giving out free care quietly and graciously for a long time. Now that Medicaid and Medicare and, increasingly, private insurance continue to reduce payments to providers, free care is becoming problematic.
So, if people refuse to buy insurance, would it not be consistent to say that providers should be able to refuse them free service? OK...I know what you are going to say. Car insurance covers people to drive and driving a car is a privilege not a right. No insurance, no license. Living is not a privilege, it is a right--one does not require a state license to keep breathing. There is also that pesky little document that says something like "life, liberty and the pursuit of happiness....".
Life is a right and the state would never take that right away. But wait....it does. The death penalty is still legal. So, the State does on occasion take a life away--so should one conclude that living is a privilege and not a right?
The reimbursement problem in healthcare is a huge problem which significantly adds to the cost of healthcare for all. If the Supreme Court is going to weigh in on this, perhaps they should write an opinion which clarifies in which direction this should head. I am certain that they have all read Hegal and are familiar with his argument. The real question becomes if they or any other of our leaders have the political will to gravitate toward a reasonable, consistent, non-contradictory policy. I am not holding my breath.
The short version is the question: does the Congress have the right, under the commerce clause of the constitution, to force citizens to buy health insurance. This is called the individual mandate. The secondary question is: if the individual mandate is unconstitutional, is the whole bill unconstitutional?
I am no legal scholar and will make no predictions about how this will turn out...however, I recall the philosopher, social scientist, political scientist and trouble maker Hegal, who famously suggested that the argument that has the fewest internal contradictions should prevail. Following that logic, I would like to know that if the Supreme Court finds that Congress cannot compel citizens to buy health insurance, can hospitals and physicians and other providers begin to refuse to treat people who have no insurance and who refuse (or are unable) to pay? Decades ago, it became illegal for any health care facility to refuse treatment based on his or her ability to pay. Then the infamous HIPPA legislation made it illegal to even ASK patients in the emergency room if they had insurance before they underwent at least an initial medical evaluation. Health Care facilities have been giving out free care quietly and graciously for a long time. Now that Medicaid and Medicare and, increasingly, private insurance continue to reduce payments to providers, free care is becoming problematic.
So, if people refuse to buy insurance, would it not be consistent to say that providers should be able to refuse them free service? OK...I know what you are going to say. Car insurance covers people to drive and driving a car is a privilege not a right. No insurance, no license. Living is not a privilege, it is a right--one does not require a state license to keep breathing. There is also that pesky little document that says something like "life, liberty and the pursuit of happiness....".
Life is a right and the state would never take that right away. But wait....it does. The death penalty is still legal. So, the State does on occasion take a life away--so should one conclude that living is a privilege and not a right?
The reimbursement problem in healthcare is a huge problem which significantly adds to the cost of healthcare for all. If the Supreme Court is going to weigh in on this, perhaps they should write an opinion which clarifies in which direction this should head. I am certain that they have all read Hegal and are familiar with his argument. The real question becomes if they or any other of our leaders have the political will to gravitate toward a reasonable, consistent, non-contradictory policy. I am not holding my breath.
November 26, 2010
Adventures in the Urologist's Office
Being a strict adherent to Murphy's laws, I peed blood the day before traveling overseas. Knowing full well that this was cancer until proven otherwise, I made an appointment for the day after my return--there was no way I was surrendering my trip.
Seated nervously in the waiting room, I found that the only available reading material was the current issue of Cosmopolitan. What strange reading material for a Urology office. The lead article was "50 Ways To Keep Your Man Happy in Bed." I began to imagine that I had entered a Fellini movie. At 61, I was, by far, the youngest patient there; I doubt if any of these men wanted to be reminded of their diminished or totally absent sex lives. Hello... this is a Urology office.
An attractive, young, blond nurse escorted me into an exam room. Even by Doctor's Office standards, this room was stark. No art, no pictures...nothing. Having a high familiarity with exam rooms, I decided to poke around to pass the time; I had left my issue of Cosmo in the waiting room. The first drawer that I opened had a stack of paper gowns with an old, beat up pair of Channel lock pliers sitting on top. What the hell do they use those for??? Well--obviously--for adjustments to your genitals. I decided to quit poking around.
The doctor came in and took a short history. He suggested an IVP and a cystoscopy for a workup. I agreed to the cysto and, if that were negative, to negotiate the need for the IVP xray exam. I readily agreed to do the cysto right away since I did NOT want to come back again.
The nice, young, blond nurse took me into the procedure room where she told me, unceremoniously, to drop my pants and lie down on the table. She stood with her back to me while I complied; the formality of undressing and putting on a gown was skipped. Just drop trou...at least, I wasn't asked to bend over. (I will cover colonoscopy in another blog.)
I almost fell asleep waiting for the procedure to begin. In came the Urologist and explained the procedure. It was to be a Fellini movie after all....I got to watch the whole thing on the tv monitor. He held my manhood in his left hand and injected some lubricant into my urethra with his right hand. Oh boy. This was quickly followed by the cystocope, a flexible tube with a lens on the end as well as ports to add water or suction water or take biopsies as necessary. I could not decide which was worse: following the scope up my urethra on the monitor or watching him push the scope up my penis. My bottom was quickly soaked with the overflow of water used to improve visability. Aha...there's the problem: he found a stricture in the urethra where I had had Radiation for my Prostate Cancer four years earlier. He said it was tight and he might not be able to break through and finish the examination.
He said it might hurt a bit and I encouraged him to go for it. I went, back and forth, from watching the monitor to watching him, manhood in left hand and scope in right hand, pushing back and forth to try to break open the obstruction. I could not help but envision a pile driver; but without the noise. The pain was as much psychic as physical. After a minute or so (which seemed like an hour), he popped through into the bladder and finished the exam. No cancer. No need for further workup.
In a flash, he was gone. Having had my cherry popped, I turned to the nurse, who probably assists on a half-dozen of these a day, and said: "Do you think I put out too much for a first date?" She cracked up.
I bled for a couple of days but was relieved to know I was free of serious pathology and, more importantly, was relieved to have this whole episode in my rear-view mirror. Many would complain that this episode reflects the new health care system; personally,I was quite pleased to have a serious problem dealt with quickly and efficiently. I would send my patients to this office with no reservations. It could have been worse; he might have pulled out the channel lock pliers.....
Seated nervously in the waiting room, I found that the only available reading material was the current issue of Cosmopolitan. What strange reading material for a Urology office. The lead article was "50 Ways To Keep Your Man Happy in Bed." I began to imagine that I had entered a Fellini movie. At 61, I was, by far, the youngest patient there; I doubt if any of these men wanted to be reminded of their diminished or totally absent sex lives. Hello... this is a Urology office.
An attractive, young, blond nurse escorted me into an exam room. Even by Doctor's Office standards, this room was stark. No art, no pictures...nothing. Having a high familiarity with exam rooms, I decided to poke around to pass the time; I had left my issue of Cosmo in the waiting room. The first drawer that I opened had a stack of paper gowns with an old, beat up pair of Channel lock pliers sitting on top. What the hell do they use those for??? Well--obviously--for adjustments to your genitals. I decided to quit poking around.
The doctor came in and took a short history. He suggested an IVP and a cystoscopy for a workup. I agreed to the cysto and, if that were negative, to negotiate the need for the IVP xray exam. I readily agreed to do the cysto right away since I did NOT want to come back again.
The nice, young, blond nurse took me into the procedure room where she told me, unceremoniously, to drop my pants and lie down on the table. She stood with her back to me while I complied; the formality of undressing and putting on a gown was skipped. Just drop trou...at least, I wasn't asked to bend over. (I will cover colonoscopy in another blog.)
I almost fell asleep waiting for the procedure to begin. In came the Urologist and explained the procedure. It was to be a Fellini movie after all....I got to watch the whole thing on the tv monitor. He held my manhood in his left hand and injected some lubricant into my urethra with his right hand. Oh boy. This was quickly followed by the cystocope, a flexible tube with a lens on the end as well as ports to add water or suction water or take biopsies as necessary. I could not decide which was worse: following the scope up my urethra on the monitor or watching him push the scope up my penis. My bottom was quickly soaked with the overflow of water used to improve visability. Aha...there's the problem: he found a stricture in the urethra where I had had Radiation for my Prostate Cancer four years earlier. He said it was tight and he might not be able to break through and finish the examination.
He said it might hurt a bit and I encouraged him to go for it. I went, back and forth, from watching the monitor to watching him, manhood in left hand and scope in right hand, pushing back and forth to try to break open the obstruction. I could not help but envision a pile driver; but without the noise. The pain was as much psychic as physical. After a minute or so (which seemed like an hour), he popped through into the bladder and finished the exam. No cancer. No need for further workup.
In a flash, he was gone. Having had my cherry popped, I turned to the nurse, who probably assists on a half-dozen of these a day, and said: "Do you think I put out too much for a first date?" She cracked up.
I bled for a couple of days but was relieved to know I was free of serious pathology and, more importantly, was relieved to have this whole episode in my rear-view mirror. Many would complain that this episode reflects the new health care system; personally,I was quite pleased to have a serious problem dealt with quickly and efficiently. I would send my patients to this office with no reservations. It could have been worse; he might have pulled out the channel lock pliers.....
October 28, 2010
Arrogance
The Juan Williams' firing underscores everything that is wrong with traditional main stream media. Eight million Americans have lost their jobs over the past 2 years--the vast majority lost their jobs through no fault of their own. Juan Williams was fired for cause--I think that the cause was pretty weak but the only opinion that matters is his boss's opinion.
As an independent, I watch PBS, FOX, CNN as well as other news sources. I liked that Juan Williams appeared on many venues--he had a nice, moderate, sensible take on current events. He balanced the extreme views of the right and the left quite nicely....until he played the race card and claimed that he was fired because he didn't play the role of the lackey black man (that was expected of him). What a waste. Why do the talking heads think that they do not play by the same rules as the rest of Americans....that they can be fired, demoted or used as needed by their employers?
At 61 years old, I have joined the young and look to Jon Stewart (The Daily Show) for more meaningful news than the traditional sources. NO ONE gets a free pass on his show. He exposes the hypocritical attitudes of not only the politicians but also (and most vehemently) the pundits who cover them. The public has become less and less tolerant of the slow intimate dirty dance going on between politics and media.President Obama, an astute politician, decided to appear on The Daily Show for good reasons.
Mr. Williams was awarded a $2 million dollar contract from FOX within 48 hours of his firing--way more money than a brain surgeon makes...and political commentary is not brain surgery. Perhaps big money is as big a problem in the media as it is in politics.
Several commentators have complained that Obama's appearance on the Daily Show, for a 30 minute interview, demeaned the office of the Presidency. This is sour grapes...they wish that they had scored the interview. Maybe if they were a little more relevant and a little less arrogant, shrewd politicians (as Obama certainly is) would sit with them for thirty minutes. It is simultaneously ironic and sad that we have to turn to the Comedy Channel for serious dialog.
October 6, 2010
Look forward...plan back
Recent data shows that the United States now spends 17% of GDP on health care. This is just over one dollar out of six. Other advanced countries, with similar or better quality indicators, spend 8-12%. Some experts suggest that this expense could reach 25%--one dollar out of four--by the end of the new decade. Ouch....
A number of factors are contributing to this spiraling cost. The baby-boomer generation is approaching age 65--this tsunami of demographic statistical significance will flood the available resources. New procedures, drugs and treatments march ever forward. The Dartmouth Atlas reveals wide variation in the appropriate use of common medical procedures. Medical practice is increasingly fragmented into smaller and smaller quanta; today, it takes a village of practitioners to take care of patients. Surgeons sub-specialize not only into fields (say Orthopedics) but also into one specialty procedure (such as arthroscopic surgery on the shoulder). An endocrinologist will manage your diabetes but wants nothing to do with your blood pressure or cholesterol. This fragmentation improves the treatment of individual problems while ignoring the patient's overall well-being; your care is being deconstructed. It also maximizes total revenue.
American Corporations face increasing headwinds in global competition. Two striking ones are corporate taxes (nearly the highest in the world) and the highest health care costs in the world. Not only do companies in other developed countries pay lower corporate income taxes, most pay NO health care costs as they are underwritten by the state. If health care costs spike to 25% by 2020, how will American companies be able to compete with foreign companies who do not face these costs? Would it surprise you if they invested their profits overseas?
Health care experts agree that the trifecta of health care reform would address three issues: access, quality and cost. Obamacare seriously addressed only one..access. Access to our existing dysfunctional system has been expanded; quality will probably stagnate and costs will continue their upward spiral.
Game Theory tells us to look forward and plan back. What will be the public policy response when health care costs hit 25%? No doubt, the system will be capped and any new additional medical expense will have to be balanced by a reduction in some other medical area. Politicians call this pay-as-you-go. Economists call it a closed system.
Well then, if we know that we are hurtling toward a cap, why don't we start initiating a cap now with a pay-as-we-go program? If we eased into a flexible cap now, we would have time to work out the kinks before we hit that brick wall down the road.
Some sort of cap would FORCE us to develop programs with more bang for the buck than what we are getting now. Health care cannot be an open ended commitment to everything...we simply cannot afford it. Unfortunately, the politicians would pick winners and losers...those who are politically astute would be favored; the dis-enfranchised would suffer. These groups already know who they are. It will take time to develop a more equitable balance; that time is only available if we start seeking out ways to get more value for our health care dollars now--not when we hit that brick wall of 25%(which is not far off). Starting a flexible cap now would give us time to work out the political problems: the recent furor over mammograms is an excellent example of the resistance that will accompany any radical change to the status quo.
We spend 2.5 trillion dollars a year on health care; we deserve to get more for that expense than we are currently receiving. We need to cull unnecessary treatments and use the savings to develop newer treatments that are even more effective. It is not rocket science figuring out what works...it just takes political will. I am not optimistic.
A number of factors are contributing to this spiraling cost. The baby-boomer generation is approaching age 65--this tsunami of demographic statistical significance will flood the available resources. New procedures, drugs and treatments march ever forward. The Dartmouth Atlas reveals wide variation in the appropriate use of common medical procedures. Medical practice is increasingly fragmented into smaller and smaller quanta; today, it takes a village of practitioners to take care of patients. Surgeons sub-specialize not only into fields (say Orthopedics) but also into one specialty procedure (such as arthroscopic surgery on the shoulder). An endocrinologist will manage your diabetes but wants nothing to do with your blood pressure or cholesterol. This fragmentation improves the treatment of individual problems while ignoring the patient's overall well-being; your care is being deconstructed. It also maximizes total revenue.
American Corporations face increasing headwinds in global competition. Two striking ones are corporate taxes (nearly the highest in the world) and the highest health care costs in the world. Not only do companies in other developed countries pay lower corporate income taxes, most pay NO health care costs as they are underwritten by the state. If health care costs spike to 25% by 2020, how will American companies be able to compete with foreign companies who do not face these costs? Would it surprise you if they invested their profits overseas?
Health care experts agree that the trifecta of health care reform would address three issues: access, quality and cost. Obamacare seriously addressed only one..access. Access to our existing dysfunctional system has been expanded; quality will probably stagnate and costs will continue their upward spiral.
Game Theory tells us to look forward and plan back. What will be the public policy response when health care costs hit 25%? No doubt, the system will be capped and any new additional medical expense will have to be balanced by a reduction in some other medical area. Politicians call this pay-as-you-go. Economists call it a closed system.
Well then, if we know that we are hurtling toward a cap, why don't we start initiating a cap now with a pay-as-we-go program? If we eased into a flexible cap now, we would have time to work out the kinks before we hit that brick wall down the road.
Some sort of cap would FORCE us to develop programs with more bang for the buck than what we are getting now. Health care cannot be an open ended commitment to everything...we simply cannot afford it. Unfortunately, the politicians would pick winners and losers...those who are politically astute would be favored; the dis-enfranchised would suffer. These groups already know who they are. It will take time to develop a more equitable balance; that time is only available if we start seeking out ways to get more value for our health care dollars now--not when we hit that brick wall of 25%(which is not far off). Starting a flexible cap now would give us time to work out the political problems: the recent furor over mammograms is an excellent example of the resistance that will accompany any radical change to the status quo.
We spend 2.5 trillion dollars a year on health care; we deserve to get more for that expense than we are currently receiving. We need to cull unnecessary treatments and use the savings to develop newer treatments that are even more effective. It is not rocket science figuring out what works...it just takes political will. I am not optimistic.
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