Now online from the July 2nd New York Review of Books, but posted June 3rd, is "The Health Reform We Need & Are Not Getting" by Arnold Relman, Professor Emeritus of Medicine and Social Medicine at Harvard Medical School and former Editor in Chief of The New England Journal of Medicine. After discussing the factors causing the amazingly high cost of US healthcare, mostly commercialization of medical care and the effect of investor owned provisioning of care and for-profit insurance Relman notes:
When considered in the light of what has been said about health costs, the proposals now being debated in Washington seem to be missing the main target. They will expand insurance coverage in the short term, which is certainly needed, but they will create a system even less affordable than at present. (My emphasis)
SNIP
In seeking a consensus, Obama's health reform policies do not address the central causes of rising costs, and propose nothing likely to have much effect on them. He does not mention the ways that investor ownership and the fee-for-service payment system provide incentives for increasing costs. Nor do his policies recognize as a major problem the fragmented, entrepreneurial organization of a medical care system that is dominated by specialists and is deficient in primary care doctors. And yet reforms that do not address these problems cannot produce an affordable or sustainable system.
Relman offers a very good, comprehensive analysis of what's "on the table," and includes Ezekiel Emanuel's proposal, which, while better than what's being considered in Congress, leaves the commercialization of care procedures and for-profit players in place and thus loses the ability to control the biggest cost centers. Ezekiel also proposes paying for healthcare through a VAT tax, a less progressive form of taxation.
Relman closes by saying single payer is the logical solution, but that too many, including Ezekiel Emanual, tend to view single payer as government paid/government owned provisioning, not the government paid/private provider model. He feels it is impossible now--that things will have to get even worse.
Neither my proposal, nor Emanuel's, nor Conyers's, nor any other plan that starts with the elimination of private employment-based insurance and depends largely on public funding stands much of a chance of being enacted now. It would be too great a change, and it would threaten insurance companies and other powerful vested interests that influence Congress. The same is true of any major reorganization of medical care that phases out fee-for-service practice in favor of nonprofit multispecialty groups of salaried physicians and dampens the commercial fire that has converted US medical care into an ever-expanding profit-seeking industry.
As bad as they already are, things will have to get still worse before major reform becomes politically possible. The legislation likely to emerge from this Congress will not control—and will probably even exacerbate—the inflation of costs. But sometime in the not-too- distant future, health expenditures will become intolerable and fundamental change will at last be accepted as the only way to avoid disaster. When that time arrives, the opportunity to enact real health reform will finally be at hand. (My emphasis)
Longish, but well worth reading. He points out clearly where the real costs are. What's frightening is that it seems the debate has degenerated to the level of saying the needs of people for healthcare are the cost problems.
BOHICA, baby.
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What do you mean, "degenerated"?
That's been the FKDP
's perspective, and Obama's talking point, from the very beginning.
"First they ignore you, then they ridicule you, then they fight you, then you win." -- Mahatma Gandhi
we need to stop demonizing fee for service
otherwise, a great read, thanks.
all other countries with true universal health care utilize fee-for-service, not exclusively in some cases, but at least as much as we do, and possibly more.
they also generally do not have the large, integrated, salaried-physician groups [like mayo clinic] that we do, so this model, while good, isn't necessary. where you generally see the salaried-physician models is in the countries with fully nationalized health services, like spain and britain [and our vha].
all the ways of paying for health care are imperfect and have flaws that can be exploited for profit maximization.
capitation? that's what hmos do -- a flat per-month fee to take care of you, no matter how well or how sick.
drg? that's short for diagnosis related group, which is how medicare pays for hospitalizations [also known as bundling] -- a flat fee [with some modifications] for your broken hip, however broken it may be.
salaries? mayo clinic, cleveland clinic, kaiser permanente, some other large groups, some hospitals, the vha -- lots of places pay their physicians a straight salary, and lots of doctors are happy with the arrangement -- leaves them free to practice medicine and not worry about the business end of things.
fee for service? that's $100 for one test, $200 for two tests, etc -- each service is paid for individually.
fee-for-service, as everybody and their cousin has been pointing out lately, provide some incentive to overtreat people, why get paid for giving just an x-ray when you can be really, really sure and order a ct scan and an mri too?
capitation and bundling provide incentives to undertreat. see gob's comment here for a real-life, close-to-home example [and my reply to see that it's systemic].
salaries, of course, can be a reward for just showing up and doing a minimal job. doctors generally become doctors to help people, so this probably isn't widespread, but it's not the panacea the very serious people are making it out to be. mayo and cleveland clinics may provide good, low-cost care, but they're also charging corporate fatcats an arm and a leg for 'executive physicals' to make up for some of that.
so how do all these other countries control costs? government-imposed price controls, plain and simple, and all or mostly non-profit hospitals [and non-profit insurance companies if they're in the mix].
not that the corporatist fkd party wants to do any this.
I distrust analyses with abstract actors and passive verbs
sometime in the not-too- distant future, health expenditures will become intolerable and fundamental change will at last be accepted as the only way to avoid disaster. When that time arrives, the opportunity to enact real health reform will finally be at hand.
Health expenditures will become intolerable to whom? To the elites, I presume, because they already are to the people. Medical costs are a major cause of bankruptcy. Twenty to thirty thousand U.S. residents die each year from lack of access to appropriate medical care. And that leads to what kind of fundamental change that will be accepted? The change may well be the complete abandonment of any attempts to provide medical care to the lower orders, because "we can't afford it".
We can't have real health reform now because the concentration of wealth has replaced democracy with oligarchy. The productivity of the country is drained off for the continued enrichment of the oligarchs, who use it for robust naked power both at home and abroad. These trends are increasing rather than reversing. So where's this opportunity for reform going to come from?