Obamacare conundrum: Good, universal, cheap. Pick two.

Andrea McArdle updates the old engineers' dictum after seeing (1) big losses among Massachusetts health insurers, (2) new subscribers gaming the system and (2) a governor who doesn't seem to understand that price controls never work.

President Obama, please take note.

How to put the the insurance back into health "insurance"

Michael Tanner of the Cato Institute makes the case for high-deductible health care insurance:

But both sides seem curiously unwilling to address the most important participant in the health care equation - the consumer.

Democrats appear to see consumers only as a class needing protection. Their focus is almost exclusively on government action.

Republicans at least give lip service to a consumer-focused health care system, but seem reluctant to really endorse proposals that shift more risk and responsibility to those consumers.

Perhaps that is because in the long-run, the only way to spend less on health care is to consume less health care.

Obama borrows from Nixon playbook in bid to lower health care costs

What is it with left-of-center public servants emulating Richard Nixon these days?

As Reason's Steve Chapman sees it, President Obama has hopped on the Nixon policy bandwagon in a big way:

So how does Obama intend to make health insurance affordable? He wants the federal government to regulate premiums from coast to coast.

This approach mirrors Nixon's disastrous wage and price control program. Chapman relates how it worked out for Nixon:

Nixon's own chief economist, Herbert Stein, admitted that the administration eventually had to give up because the program was "a total disaster." Among the unwanted side effects: "Cattle were being withheld from market, chickens were drowned, and the food store shelves were being emptied." Motorists had to wait in line for hours to buy gasoline. At one point, Americans faced a nationwide shortage of toilet paper. Yes, toilet paper. Oh, and the inflation rate didn't fall. It rose.

I wonder what President Obama will try when he finds out that price controls don't work. Ford-style sloganeering?

Social networking for sick people: PatientsLikeMe.com

[UPDATE: a formula stimulated by a friend's comment: social network + shared data = better patient outcomes.]

Wow.

If you or a loved one is dealing with a major (or minor) health problem, you really MUST check out PatientsLikeMe.com.

My first reaction to the website: brilliantly conceived and wonderfully implemented.

I've only taken a quick look at it, but the site lets anyone with a disease or medical problem find others going through exactly the same ordeal. You can share your personal story and your opinions of the drugs and treatments you're going through and see what others think of theirs.

The site also lets you look at aggregate data. For example you can see which medicines and treatments are most commonly prescribed for your condition.

And that seems to be just the tip of the iceberg.

Watch the Jamie Heywood's inspiring TED video:


Then check out the PatientsLikeMe.com website.

Obama's SOTU: a huge contradiction & a collapsed soufflé

[UPDATE: Don't-Say-I-Didn't-Warn-You Department: The "answer to everything" link below delivers an oddly apt simulation of Washington DC as experienced by the average voter.]

Peggy Noonan spots the contradiction:

The central fact of the speech was the contradiction at its heart. It repeatedly asserted that Washington is the answer to everything. At the same time it painted a picture of Washington as a sick and broken place.

With her speechwriter's eye, she also picks up on subtle-but-telling indications that Obama has given up on the health care bill:

Waxing boring on the virtues of the [health care] bill was a rhetorical way to obscure the fact that it is dead. . . . The bill will now get lost in the mists and disappear. It is a collapsed soufflé in an unused kitchen in the back of an empty house.

For what it's worth, a poll on the non-partisan Open Congress website currently shows 78% of participants opposing the Senate version of the healthcare reform bill.

"when all Democrats are indispensable, every Democrat can be an extortionist"

George Will, writing about the health care bill in the WaPo:

So there have been serial purchases of 60th votes for health legislation. This squalid commerce (special benefits tailored for Florida's Medicare Advantage clients, for Louisiana and Nebraska, and for union members) did almost as much as the legislation itself to discredit the entire sorry business.

George has been full of energy lately. I think the Obama administration has invigorated him.

Ellen Sauerbrey's formula for health care reform

Here's her list, from an article she wrote for RedMaryland:

1. Tort reform
2. A tax break for those without employer-based health insurance (e.g. waitresses) that equals the tax break given to those with employer-based insurance (e.g. corporate executives).
3. Allow Maryland citizens to buy health insurance policies in other states (including stripped-down ultra-basic policies that (1) don't cover small, foreseeable expenses, and (2) don't force consumers to pay for the many, many extras mandated by the Maryland General Assembly)
4. Fix the problems in Medicare and Medicaid before expanding them rather than after.

It's a good list.

"Human rights are the wrong basis for healthcare"

Congressman Ruppersberger, please take note.

Willam Easterly, an economist at NYU, had a nice op-ed piece in the Financial Times a few weeks ago.

He gives some history and context:

• The notion of a “right to health” has its origins in the United Nations’ Universal Declaration of Human Rights in 1948.
• The [World Health Organization] shifted from pragmatic improvement of health outcomes towards “the universal realisation of the right to health”.
• Even Amnesty International . . . added a new section to its human rights report in 2009 on the “right to health”.
• President Barack Obama recently held a conference call with religious leaders in which he called healthcare “a core ethical and moral obligation”.

Unfortunately, all of these groups--and President Obama--are on the wrong track. Their intentions might be good, but their efforts seem counter-productive:

the global campaign to equalise access to healthcare has had a surprising result: it has made global healthcare more unequal.

Why is the concept of "healthcare as human right" so flawed and problematic?

It is impossible for everyone immediately to attain the “highest attainable standard” of health (as the health rights declaration puts it). So [the question of] which “rights to health” are realised [becomes] a political battle. Political reality is that such a “right” is a trump card to get more resources – and it is rarely the poor who play it most effectively.

The lesson:

The pragmatic approach – directing public resources to where they have the most health benefits for a given cost – [has] historically achieved far more than the moral approach . . .

[The concept of a] “right” [to healthcare] skews public resources towards the most politically effective advocates, who will seldom be the neediest.

The bottom line: those who frame health care as a "right" are serving up empty rhetoric.

Explaining the obvious to Michelle Goldberg

In a diavlog last month on BloggingHeads.tv, Michelle Goldberg claims--with astonishing arrogance, condescension, and superficiality--that she doesn't understand why so many folks are opposed to the health care reform bills (32-second clip):

Some responses to her questions & assertions.

ITEM #1. "Do [Townhall protesters] think the current system is acceptable?"

RESPONSE: No. The people who say at town halls that they are "satisfied" with their current health care plans are probably either (1) healthy younger folks who don't have to deal much with the current system and/or fear that they will have to shoulder more of the burden by subsidizing older folks, or (2) they are retired or soon-to-be-retired folks who fear losing elements of their existing Medicare coverage. Both of these fears are warranted, and people tend to fear losing something they already have more than they relish getting new benefits that they don't already have.

ITEM #2. "The worst part is the paperwork"

RESPONSE: Duh. Most people who have dealt with the system agree that the paperwork is awful. I'm just not confident that reform bills proposed by Democrats will reduce paperwork. Expanding government programs hasn't been a good formula for that in the past.

ITEM #3 "There's lots of misguided love for insurance companies among reform opponents."

RESPONSE: Matt Welch--he's amazingly polite to her--does a terrific job of dismantling this assertion, which is just not true. (Clip below, length 1:58, is different from one above):

ITEM #4. "Jim Wilson [yada yada] Glenn Beck. You can't argue 'death panels' and you can't argue 'totalitarianism' "

RESPONSE: If you revisit Aristotle's Rhetoric--the part on style in Book 3--you'll see that use of metaphors is one of the most powerful and effective methods of persuasion and argument. Opponents of health care reform use the terms "death panel" and "totalitarianism" as metaphors for rationing and encroaching government. Yes, they are gross exaggerations. But these metaphors (especially the death panel one) have touched sensitive nerves in the public. So yes, you actually CAN argue death panels and totalitarianism. And responses to these arguments (from Pelosi et al.) have been weak and unconvincing.

ITEM #5. "Just give me something like the French health care system."

RESPONSE: I'm no expert on the French health care system, but some quick Googling indicates that the French system does not suffer from problems the U.S. has with malpractice insurance, defensive care, and the tort system. This means that one of the key steps for getting us to something like the French system is tort reform. To my knowledge, the current Senate bill does little or nothing to deal with this issue.

ITEM #6. The reasons for opposition are "more psychological than economic".

RESPONSE: This was the most condescending of all her statements. If Michelle had looked to some of the more thoughtful folks presenting alternatives to the reform bills she would have found plenty of economic reasons to criticize the reform bills. I can think of three examples:

I. Check out David Goldhill's piece in the Atlantic Magazine How American Health Care Killed My Father. His suggestions:

• Move away from comprehensive health care as the single model for finance health care.
• Put the consumer, not the government at the center of the system.
• Give government the primary task of bringing greater transparency and competition to the health care industry and directly subsidizing those who can't afford care.
• Fund routine care out-of-pocket (not covered by insurance) so the people who care most about cost--consumers--are in their proper, primary role of trading off price, quality and value.
• Fund massive, unpredictable expenses with insurance.
  
• Replace our current web of employer- and government-based insurance with a single [mandatory] program of catastrophic insurance open to all Americans. . . with fixed premiums based solely on age. . . a single national pool, without underwriting for specific risk factors [that] would ultimately replace Medicare, Medicaid and private insurance. [With a high threshold for defining "catastrophic" at approximately $50,000 or more.] Limit insurance payouts in any year to the amount of available premiums.
• Over time, shift over to funding all non-catastrophic care from an improved, mandatory version of HSAs.
• Fund intermediate level expenses (e.g. appendectomies) just as we do things like new cars: with credit. But allow people to borrow against future deposits into their HSA.

The bottom line for this approach:

Imagine how things might change if more people were buying their health care the way they buy anything else. I’m certain that all the obfuscation over prices would vanish pretty quickly, and that we’d see an end to unreadable bills. And that physicians, who spend an enormous amount of time on insurance-related paperwork, would have more time for patients. . . .

It will do a better job than our current system of controlling prices, allocating resources, expanding access, and safeguarding quality. And it will do a better job than a more government-driven approach of harnessing medicine’s dynamism to develop and spread the new knowledge, technologies, and techniques that improve the quality of life. We won’t be perfect consumers, but we’re more likely than large bureaucracies to encourage better medicine over time.

II. Dr. Peter Weiss of Medically Incorrect makes many of the same points in this video. Dr. Weiss's prescription for reform includes the following items:

1. Increase competition among insurance companies by allowing them to compete across state lines.
2. Allow people to buy health insurance through affinity groups like AAA or Costco without regard to pre-existing conditions (just as employees get insurance through large employers).
3. For employees who lose their jobs, allow them to buy COBRA insurance at the employer was paying (not the double or triple rate that COBRA charges).
4. Strive for major illness insurance. Insurance is meant for catastrophes, not for everyday expense. Make people pay out of their own pocket for small predictable expense like office visits and PAP smears.
5. Have a system where consumer must take ownership of expenses (because cost is the main culprit, not access or quality).

III. Then, there's Congressman/Doctor Tom Price's alternative bill titled Empower Patients First (H.R. 3400). It suggests:

• Fix the unfairness in the tax treatment of health insurance by extending a tax credit or deduction to those without employer-sponsored insurance;
• Use automatic enrollment, with a right to “opt out” of health insurance coverage, and promote defined-contributions for employer plans, instead of using government coercion and mandates, to expand coverage;
• Establish health plan portals in the states so that patients can own and control their own health insurance;
• Offer low-income Americans the option of a voucher to purchase private coverage; and
• Give states incentives to experiment with how best to cover high cost individuals.

The full clip on health care is here (length 10:52):

Obama's timidity on malpractrice reform

Toward the end of his big health care speech last night, President Obama decried the current state of affairs where

only timidity passes for wisdom.

Fourteen paragraphs earlier, he said this:

I don't believe malpractice reform is a silver bullet, but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs.

May be contributing? Ya think?

Please read David Goldhill's article on healthcare in the September issue of The Atlantic

I stopped in at Dutch Ruppersberger's Timonium office last week and dropped off a copy of Mr. Goldhill's article. The title is How American Health Care Killed My Father.

I attached a note to Dutch that said (roughly):

Dear Dutch -- This article is one of the best pieces of analysis and explanation that I have read on any topic, ever. Please read it. I hope you will incorporate parts of it in your thinking and in your public statements on health care. After you read it, I'd like to discuss it with you. Please call me on my cell at 410-xxx-xxxx.

Thank you.

To everyone else out there, please read the article and send a copy of it to your Congressman.

By the way, Dutch has scheduled a town hall conference call for September 21st at 7:30 PM. Details such as the call-in number and passcode are TBD.

What health insurance reform should give us: a cheap, high-deductible catastrophic policy.

Which is exactly what none of the current bills would let us have, according to John Stossel:

Consumers could not buy a cheap, high-deductible catastrophic policy [under any of the existing bills currently floating around the House and Senate]

Read the whole thing.

Last week I asked a customer service rep at Maryland's dominant health insurer* if they sell such a policy. She said no, making it sound as if selling catastrophic insurance without the "basic" plan would be an impossibly difficult feat.

At the end, Stossel adds:

Profit is the key to competition. Anyone who claims to favor competition but looks down at profit has no idea what he is talking about.

Well said.

*CareFirst Blue Cross/Blue Shield

Maryland has forced more mandates on health care insurers than any other state

Robert Moffit of the Heritage Foundation, citing a 2001 Blue Cross/Blue Shield study:

Maryland leads the nation with at least 52 mandates on private health insurance . . . Only California, which has 43 mandates, comes close to Maryland.

There seem to be three types of mandates relating to (1) conditions/treatments/services (28 mandates), (2) providers (18 mandates) and (3) patient classes (6 mandates). Here are the mandates relating to conditions, treatments & services:

Alcoholism Treatment
Bone Density Screening
Breast Reconstruction
Cleft Palate
Clinical Trials
Colorectal Screening
Contraceptives
Dental Anesthesia
Diabetic Supplies/Edu
Drug Abuse Treatment
Emergency Services
Formula for PKU
Hair Prostheses (Wigs)
Home Health Care
Hospice Care
Invitro Fertilization
Mammography Screening
Maternity
Mental Health (General)
Mental Health (Parity)
Minimum Mastectomy Stay
Minimum Maternity Stay
Off-Label Drug Use
Orthotics/Prosthetics
Prostate Cancer Screening
Rehabilitation Services
Second Med/Surg Opinion
Well-Child Care

A doctor told me last week that these mandates have driven up health insurance premiums in Maryland. And contributed to declining number of insurers competing in the Maryland market.

Thoughts on health insurance reform from a small-business owner in Maryland

I heard Mike Vallerie talk on the Kendel & Bob Ehrlich Show this morning. He came across as thoughtful, fair and practical. His four key ideas:

1. Tort reform modelled on worker's comp.
2. Roll back the definition of health insurance so that it really is insurance: "A means of indemnity against occurrence of an uncertain event."
3. Individuals should be responsibe for taking care of themselves (i.e. paying for expected, forseeable expenses), and
4. Level the playing field so that small businesses get a fair shake compared to big business.

His website is MikesPlan.net.

Finally! Some thoughts on health care reform that are clear, simple, honest, and to-the-point

Charles Hugh Smith gets to the root of the problem:

The corporate-America or union/government employee who goes to the doctor pays a few dollars for a visit and drugs; the “real cost” is of no concern.

More:

The link between the “consumer” of healthcare and the provider has been broken for decades. There is no “free market” in healthcare–there isn’t any market at all. We live in a Kafka-esque nightmare system in which “some are more equal than others” and hundreds of thousands of dollars are lavished on worthless tests, procedures and medications ...

And more:

So-called “defensive medicine” in which worthless tests are administered to stave off random (sometimes valid, sometimes nuisance) malpractice lawsuits.

I'll have more to say later about my recent experiences with defensive medicine.

And what does Smith recommend?:

There is a solution so simple and so radical that it is “impossible” . . . : shut down insurance and all government entitlements, and make everyone paid cash for healthcare.

How can we break the cycle of frivolous lawsuits, defensive medicine, and spiraling costs for both procedures and malpractice insurance?:

The solution to malpractice is information, not lawsuits.

What about poor people?:

Well right now they have to stand in line at emergency rooms–the most wasteful, inefficient system possible. Even “poor people” can afford a few dollars–there’s endless excuses provided yet how many “poor people” have cell phones, eat costly fast food, do costly illegal drugs, etc. etc.

Sounds about right to me.

Mr. Smith, I hope you go to Washington. We could use more people like you down there.

via Ron Smith's website

An evenhanded account of recent health-care Town Hall craziness

Tobin Harshaw provides it in the New York Times, in a column entitled "Weekend Opinionater: A Sick Debate".

Sen. Cardin Town Hall on health care: Monday 8/10/09 @ Towson U.

The details are on his website:

Health Care Town Halls

In August, I will hold town hall meetings in Hagerstown and in Towson. For planning purposes, because o the large number of people who are interested in attending, please RSVP. Space is limited at both venues so we cannot guarantee admittance. In accordance with fire regulations, when the venues are full, there will be no standing room available.

Monday, August 10th - 7 p.m.
Towson University Center for the Arts
Harold J. Kaplan Concert Hall
Corner of Cross Campus and Osler Drives
Towson, MD 21204

Parking is available across the street from the Center for the Arts on Auburn Drive off Osler Drive on Lot 13.

RSVP - sean_mckew@cardin.senate.gov.

Wilmer Eye, Part 2: my original complaint

[For background, see Part 1.]

Here's the email I sent to Dr. Peter McDonnell under the subject heading "Wilmer Eye Institute: an unhappy customer":

Dear Dr. McDonnell -- here's my story (see link below) . . . I thought you'd like to get some feedback about people's reactions to the services provided by the Wilmer Eye Institute.

By the way, [patient] is fine now and back to normal, and we are relieved and very happy about that. I just wanted to vent, and am not asking anything from you other than to be aware of the weaknesses of your organization and do your best to fix the shortcomings.

Sincerely,

Dave Greene

http://baltonorth.blogspot.com/2009/06/do-doctors-at-wilmer-eye-institute.html

Wilmer Eye Institute flunks customer service test (Part 1)

[or . . . "How not to respond to an unhappy customer" . . .]

In response to a complaint that I emailed to Wilmer's director--the email had a link to this post--I received this letter from an executive at Wilmer, Dr. J:

Mr. Greene:

My chairman, Dr. Peter McDonnell, has brought to my attention your discontent with the care that [patient] received from Dr. [B] at the Wilmer Eye Institute at Green Spring Station on [date]. I have read your blog, discussed the visit with Dr. [B], and reviewed the medical record.

It looks to me that Dr. [B] did everything from an ophthalmological standpoint to rule out any serious eye disease.

Evidently, [patient] was eventually diagnosed with Lyme disease, but I am not sure that the diagnosis of Lyme disease would have occurred to any ophthalmologist on the basis of [patient's] symptoms. I personally performed an internet search to see if I could find instances of Lyme disease presenting solely with pain in one eye upon movement, but could not find such an association.

From your blog, it seems that Dr. [B]'s style was not to your liking. Doctors are human and have personalities like everyone else, and not all doctor's styles suit every patient. I sometimes wonder how many patients leave my office upset with something that I may have said, and never let me know. All physicians recognize this and will facilitate a smooth transition to another physician when they are made aware of the concerns. We would be happy to do that in [patient]'s case if you wish and will let us know.

At Wilmer and Johns Hopkins, we are committed to improving the care that we provide, and so value the feedback that people like you give to us. Your comments will become part of our departmental Performance Improvement Program. I pledge that we will try harder to make the diagnoses, think "outside" the box when appropriate, and suggest consultation with other physicians when needed.

Sincerely yours,
Dr. [J]

cc: Peter McDonnell, Chairman, Wilmer Eye Institute ,
[Ms. X], Wilmer Patient Representative

This letter is unsatisfying and wrong-headed in so many ways, I think I'll write about it in some detail. More to come.

How much does a colonoscopy cost? Here's one answer

If we want to contain healthcare costs, one of the first obvious steps is to make sure that patients receive real prices before they have a procedure.

So, from time to time as I run across real-world healthcare prices, I'll pass them on here.

A family member recently had a colonoscopy in December 2008. Beforehand, we googled around a little to get a handle on the cost, but didn't find much. At one point just before the procedure, the patient asked one of the nurses at Greenspring Station Endoscopy how much the total cost would be. She gave a mechanic's shrug, "I don't know."

Everything went smoothly. Our patient liked the staff, was pleased with the experience, and thought Greenspring was a well-run place.

But, as with all doctors and healtcare providers, it would be a great improvement if they would publish prices (or ranges of prices) for prospective patients. In particular they should publish both the "sticker" price and the actual price.

For the nurse's benefit, and for anyone else out there who wants to know, the actual total price was $2,068. This amount, of course, becomes known only after the patient receives the bill indicating the "reduction of billed charges" negotiated by the insurance company**.

----------------------- LIST -- ACTUAL
ITEM ----------------- PRICE --- PRICE
--------------------------------------
Initial consultation.. $ 195 -- $ 130
Prep supplies............ 20 ----- 20
Anesthesia nurse........ 760 ---- 294
Endoscopy facility.... 1,500 ---- 726
Colonoscopy doctor.... 2,025 ---- 465
Lab/tissue diagnosis.... 600 ---- 433
======================================
............. TOTALS $ 5,100 $ 2,068*

*In this particular case, the procedure included cutting out a small number of benign polyps.

**In this case, CareFirst Blue Cross/Blue Shield