HR 676 - The Good and the Bad - Part 4

Continued from Part 1, Part 2, and Part 3.

Health care delivery facilities must meet regional and State quality and licensing guidelines as a condition of participation under such program, including guidelines regarding safe staffing and quality of care.

Good
This is a measure to appease people who oppose federal involvement in state affairs.

Bad
Some states insist on having unnecessarily low standards. "Best Practices" is the idea that everyone should do what has been shown to lead to the best outcomes. We are constantly measuring health care outcomes related to different policies, and it blows my mind that there are factions out there who refuse to do what is best for the people in their care. Mississippi's quidelines for quality of care are not the same as Connecticut's, and Mississippi has significantly worse health care outcomes. A single-payer has a great opportunity to use its leverage to require uniformly high standards instead of allowing states to choose whether or not they will slack off. Residents of Mississippi are still Americans, and the American government has a responsibility to them.

Participating clinicians must be licensed in their State of practice and meet the quality standards for their area of care. No clinician whose license is under suspension or who is under disciplinary action in any State may be a participating provider.

Good
Pretty standard.

Bad
Same as above about variance in state standards, but with an added gripe. It is a pain in the tuchas for clinicians to move from one state to another because licensure requirements are all different. Clinicians who live near a border are either stuck working in one direction, or have to go through multiple licensure procedures. I don't know if this constitutes an undue burden on interstate-commerce or what, but it is ridiculous. There should be at least the option of satisfying a single, high standard that would allow clinicians to move without getting a new license. There is a similar situation with gun laws, and many states accept a Florida license because it is more difficult to get than their own. Some states are easier to move to than others.

The complaints in this post are about our current system, and not about HR 676 in particular. It is just that HR 676 is accepting of these problems, and they are included in the bill. Causing as little turmoil as possible will help the bill's progress, though our system really does need some improvements.

Health Insurance Reform - Conflicts of Interest

It's been in the news for a week now that Senator Baucus's Finance Committee hearings are a total sham. With 59% of Americans asking for a single-payer system, it is absurd that the Senate would only meet with representatives from the industries that profit from the existing, inefficient private system. How could Baucus overlook representatives from single-payer supporting groups? The unfortunate and obvious answer is money.

Baucus has received "... from the insurance industry, $1,170,313; from health professionals, $1,016,276; pharmaceuticals/health-products industry, $734,605; hospitals/nursing homes, $541,891; health services/HMOs, $439,700" over his career.

"According to the report, Senator Baucus received $183,750 from health insurance companies and $229,020 from drug companies in the last two election cycles."

Insurance companies and drug companies have lots of money to spend on lobbying and campaign contributions (legal bribes). People who cannot afford health insurance also cannot afford lobbying or campaign contributions. The only way to get representation in government decision-making processes is to pay the people who get to make the decisions.

But wait... where did those figures come from? Some searching on news.google.com has only given me more blogs and op/ed pieces that cite DemocracyNow! or the 13 protesters who were arrested, heavily biased sources of information. Where can I find something more legitimate? A few seconds with Google gives me OpenSecrets.org. Let's look up our friend Max Baucus.

Three of his top 5 contributing industries and their contributions since 2005:
Insurance - $545,225
Pharmaceuticals/Health Products - $493,313
Health Professionals - $492,641

Individual contributers include Aetna, Amgen, Blue Cross, and Kindred Healthcare. For the billions of dollars these companies have riding on Baucus's actions, they are getting a pretty sweet deal. Baucus isn't alone, though. These companies donate to pretty much everybody to make sure their interests are taken into account more than the citizens of this country who do not make large financial contributions.

Something else that is interesting is that pharmaceutical companies gave 2-3 times as much money to Republicans as to Democrats until 2008. This may just reflect that we had a Republican majority in Congress until recently, but also that the Republican party values big corporate profits more than social welfare, relative to the Democratic party. Big Pharma would want to finance Republican campaigns in closer elections, but resort to just getting some leverage with Democrats in a year in which more Democrats were going to win anyway. I would like to hear other ideas.

I am glad that organizations such as OpenSecrets help give us transparency, but why isn't this information in the mainstream media? When CNN runs a story with politicians giving their policy views, it could easily and briefly mention each politician's conflicts of interest. Most people just don't know what's out there unless it's given to them, and it is the media's responsibility in a democracy to give the public relevant information.

HR 676 - The Good and the Bad - Part 3

Continued from Part 1and Part 2.

No institution may be a participating provider unless it is a public or not-for-profit institution.
Investor-owned providers of care opting to participate shall be required to convert to not-for-profit status.
The owners of such investor-owned providers shall be compensated for the actual appraised value of converted facilities used in the delivery of care.
There are authorized to be appropriated from the Treasury such sums as are necessary to compensate investor-owned providers as provided for under paragraph (3).
The conversion to a not-for-profit health care system shall take place over a 15-year period, through the sale of U.S. Treasury Bonds. Payment for conversions under paragraph (3) shall not be made for loss of business profits, but may be made only for costs associated with the conversion of real property and equipment.

Okay, this is a bit confusing, and not something that's been covered much in the media compared to the prior points. Fifty-nine percent of America’s non-federal hospitals are not-for-profit (Government Accountability Office (2008)). With a single-payer system, hospitals and other service providers will be practically forced to obey the requirements of that payer in order to stay in business. For-profit service providers will either shrink and offer only premium services at high cost to private payers (uncovered procedures or immediate procedures without waits), or they will have to make this conversion to not-for-profit status.

What do they have to convert? A common difference between for-profit (FP) and not-for-profit (NFP) hospitals is the presence of an emergency room (ER). ERs are expensive and tend to lose money, but are required for NFP status. The trade off is providing a lot of uncompensated emergency care instead of paying taxes. To work with HR 676, many FP hospitals would have to build ERs. The bill would have Treasury Bonds sold to pay for this construction, along with any other conversion costs, though I am not sure what else would be involved. They have 15 years to convert.

Good
NFP hospitals are generally more efficient than FP hospitals. It sounds like the government will pay FP investors for the conversions. 15 years is a fairly long amount of time for conversion. After transition, we will have a more efficient system overall that cares more about health care provision and less about profit.

Bad
Everyone who currently profits from their FP facilities is going to fight the bill. They will not be compensated for "lost profits". FP facilities and private insurance companies will suffer immediately as many of their customers switch insurance. NFP facilities may not be able to accommodate a sudden rise in customers. There will be a stormy transition in which we do see a temporary increase in wait times for people with the federal insurance, which the opposition will capitalize on in their complaints, and an increase in misinformation as providers and private insurance providers compete.

HR 676 - The Good and the Bad - Part 2

Continued from Part 1.

The health insurance benefits under this Act cover all medically necessary services, including at least the following:
(1) Primary care and prevention.
(2) Inpatient care.
(3) Outpatient care.
(4) Emergency care.
(5) Prescription drugs.
(6) Durable medical equipment.
(7) Long term care.
(8) Mental health services.
(9) The full scope of dental services (other than cosmetic dentistry).
(10) Substance abuse treatment services.
(11) Chiropractic services.
(12) Basic vision care and vision correction (other than laser vision correction for cosmetic purposes).
(13) Hearing services, including coverage of hearing aids.

Good
All medically necessary services are covered. One of the cost containment measures may be to reduce unnecessary testing and procedures. A huge problem with our US system is unnecessary services, also known as "defensive medicine" because they protect doctors from getting sued. People need to accept that even best practices don't always work, and it's not malpractice. Doctors should be protected from lawsuits as long as they follow best practices. This will reduce costs without disproportionately reducing quality of care. It is also good that HR 676 explicitly includes mental health and substance abuse treatment, which both have cascading effects on health and quality of life over time and generations.

Bad
"Medically necessary" will still usually mean "whatever a doctor says". Many doctors fall prey to biases in their decisions that reduce quality of care in the face of current medical research, but doctors as a group refuse to let anyone else question them, no matter how much data suggests they do something different. Large payers have had varying success controlling service provision by controlling payments per diagnosis ("prospective payment" for "diagnostically-related groups" (DRGs)), but also have had trouble spotting shenanigans like hospitals "upcoding" patients to more severe diagnoses to justify additional treatment.

Chiropractors? Seriously? They seem to have had good lobbyists since at least the early 1970's. What an unnecessary waste.

Such benefits are available through any licensed health care clinician anywhere in the United States that is legally qualified to provide the benefits.

Good
Totally standard.

No deductibles, copayments, coinsurance, or other cost-sharing shall be imposed with respect to covered benefits.

Good
No financial barriers to treatment means that everyone can afford health care. Fewer poor people avoiding basic and preventative care means fewer poor people in the ER increasing our costs and reducing their productivity.

Bad
This is an obvious lesson we should have learned from other socialized health care systems, and from experiments within the US: cost-sharing is good. When health care is completely free, people go to the doctors when they don't really need to. This is when the lines and waits get unnecessarily long. This is when practitioners' time is wasted. Even the poorest people can scrape together a $10 co-payment if they really need a doctor, and just $10 will make people think twice before running to the doctor every time they sneeze. This is not about the money as much as it is about disincentivizing waste.

We should also charge for missed appointments. Years of working providing services in poor communities has given me much experience with no-shows and last-minute cancellations. This population has many reasons for missing appointments: no transportation, the health complication itself, being unable to better schedule other necessary conflicting appointments, but often they are just not motivated to do things. The linking factor between their poor health and poverty is often that they are characterologically immediately-gratifying and avoidant of putting forth effort or exposing themselves to additional stressors such as discussing problems with a doctor. For a number of etiological reasons, they are compelled to sit at home, watch TV, eat junk food, smoke, complain, and have kids that they don't raise effectively. These behaviors lead to both poverty and health problems, and perpetuate the problems through generations. I am not saying that this describes all poor people. This is just a common issue among the poor. Service providers of Medicaid recipients are lucky to have show rates over 60%. My current clinic has instituted a number of measures to improve the show rate, and is happy to report consistent rates between 70% and 75%, and we do not get paid when the clients don't show. We use phone call reminders, and we discharge anyone who misses two consecutive appointments, but we have no cost-sharing at all. I am privy to an experiment conducted by a dental practice that serves a poor area. They tried different charges for no-shows or same-day cancellations. They found that clients were more cooperative when the charges were used for a specific and known purpose (toys and magazines for the waiting room). They also found that $20 was the sweet spot for motivating attendance. Anything less than $20, and the clients would rather stay at home and pay it. Anything over $20 and the clients would never come back. $20 kept clients on the list and coming in for appointments. Take advantage of the people's desire to avoid stressors. Make the possible loss of money more stressful than the trip to the doctor.

Charging some money makes the system more effective and efficient than making everything free.

Single-Payer Health Care

I am sure this is only the first of many times I will write about single-payer health care. I will try to keep this to a brief overview.

Ideologies:
Free-market Capitalism or Libertarianism generally support the idea that outcomes are best when companies are free to do whatever they want, and consumers are free to do whatever they want. Demand from consumers will control what companies offer and at what prices. Companies succeed that satisfy consumers the best.
Socialism generally supports the idea that consumers are best served when the government applies more control to companies to sell what the government thinks is good for the consumers.

The Current US System: We have many different private insurance companies, plus Medicare for the elderly (and ESRD), plus Medicaid for the very poor, plus S-CHIP for kids in not-rich families. The many private companies compete with each other for customers by advertising and offering different insurance packages at different prices. The US private insurance system is mostly free-market capitalist, but also has various regulations at the state and federal levels. The private insurance industry heavily lobbies congressmen and makes substantial campaign contributions to ensure that legislation is not passed that would hurt its profits. People who cannot afford insurance also cannot afford lobbyists. Politicians are not required to understand economics, ethics, or health care systems, and most don't. They often end up voting how they are told, which gives us things like Medicare Part D that explicitly prohibits Medicare from negotiating for lower drug prices.

Foreign Systems: The other industrialized nations that we usually compare the US to (European countries, Japan, Canada, Australia) are far more socialized. They can all be said to have single-payer systems, though their systems vary, because citizens have the right to most health care treatments and the government pays. The government is the single payer (a couple countries involve the government distributing funds to a handful of insurance companies based on citizen-chosen enrollment). As a single-payer, the government has great leverage that it uses to demand quality and efficiency from service providers.

Outcome comparisons: No one should ever make decisions based on belief in ideology when there is data from measured outcomes that demonstrates which system works best. The US system results in generally comparable health outcomes for the people who get health care to those in our socialized counterparts. Unfortunately, we pay about twice as much money for those comparable outcomes, and tens of millions of our citizens don't get any basic health care at all because they can't afford insurance or care. In the absence of affordable basic care, our uninsured and underinsured citizens wait until they have acute problems that cost devastating amounts of money, often causing bankruptcies and home foreclosures. Nearly half of the home foreclosures that precipitated our economic collapse were due to medical bills. This simply does not happen in single-payer systems. Money is wasted in our system on advertising and bureaucracy. If Medicare were offered to all Americans, the overhead savings would pay for the health care of our currently uninsured. With this health care, acute health problems would be reduced, and our nation's productivity and economy strengthened. America currently has the worst infant mortality rates among industrialized nations because uninsured and underinsured women cannot get effective prenatal care.

Each system does what it is designed to do. The US system is designed to make money for insurance companies that in turn give money to lobbyists and campaigns, and deny basic health care to tens of millions of people, increasing infant deaths, weakening our whole economy and bringing down quality of life. Single-payer, socialized systems are designed to give everyone adequate health care, resulting in stronger, healthier, more productive and functional nations.