Health care reform

Privacy vs coordinated care

 Health care reform  No Responses »
Apr 302008
 

Barak Obama thinks we can cut costs on health care by forcing health care providers to move to electronic records systems.

Lowering Costs Through Investment in Electronic Health Information Technology Systems: Most medical records are still stored on paper, which makes it hard to coordinate care, measure quality or reduce medical errors and which costs twice as much as electronic claims. Obama will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records, and will phase in requirements for full implementation of health IT. Obama will ensure that patients’ privacy is protected.

Never mind that one reason we haven’t done more of this already is that it does not make the most effective use of doctors’ time to do so.

And that last sentence about privacy — It seems to anticipate the article in Tuesday’s WSJ titled, “Are your medical records at risk? Amid spate of security lapses, health-care industry weighs privacy against quality care.”

But Obama doesn’t explain how he is going to ensure that patients’ privacy is protected. As it stands, his statement is the equivalent of saying he’s in favor of motherhood, apple pie, and the American flag.

One way to ensure privacy would be to make sure the people who breached the privacy of Linda Tripp’s confidential records for partisan political purposes are brought to justice. But Obama is a member of the same political party as those who made sure those violations went unpunished. Those records were not medical records, but the issue is still the same — such records can be used to intimidate and destroy political opponents.

The WSJ article says some places are trying to limit records on a need-to-know basis. For example, Lab employees only get to see lab results. So much for the stated goal of “coordinated care”.

Modernizing the U.S. Health Care System

 Health care reform  No Responses »
Apr 292008
 

Some comments on Obama’s health care platform.

Lower Costs by Modernizing The U.S. Health Care System

* Reducing Costs of Catastrophic Illnesses for Employers and Their Employees: Catastrophic health expenditures account for a high percentage of medical expenses for private insurers. The Obama plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers’ premiums.

So on the one hand he’s going to modernize. And on the other he’s going to introduce a reimbursement plan that is going to be fraught with ambiguity and corruption.

* Helping Patients:
1. Support disease management programs. Seventy five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease and high blood pressure. Obama will require that providers that participate in the new public plan, Medicare or the Federal Employee Health Benefits Program (FEHBP) utilize proven disease management programs. This will improve quality of care, give doctors better information and lower costs.

“Disease management” is the sort of thing that gave us HMOs. Look how that turned out. And now Obama is going to give us a HMO on a grander scale.

2. Coordinate and integrate care. Over 133 million Americans have at least one chronic disease and these chronic conditions cost a staggering $1.7 trillion yearly. Obama will support implementation of programs and encourage team care that will improve coordination and integration of care of those with chronic conditions.

Pre-paid health care systems such as we have encourage the un-integration of care, by requiring all diseases and treatments to be coded into strictly defined categories. It’s not enough to say Obama will try to break down the barriers between these categories, because that’s something that’s inherently against the nature of government to do. Free markets can sometimes break down existing categories. Obama has a lot of explaining to do if he thinks he can get government to do that.

3. Require full transparency about quality and costs. Obama will require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care. Health plans will also be required to disclose the percentage of premiums that go to patient care as opposed to administrative costs.

There is probably a proper role here for government, in requiring vendors to tell us just what it is they’re selling us. I wish government could be provided to do the same.

* Ensuring Providers Deliver Quality Care:
1. Promote patient safety. Obama will require providers to report preventable medical errors and support hospital and physician practice improvement to prevent future occurrences.

Defining what “preventable” is going to provide a great opportunity for ambiguity and corruption.

2. Align incentives for excellence. Both public and private insurers tend to pay providers based on the volume of services provided, rather than the quality or effectiveness of care. Providers who see patients enrolled in the new public plan, the National Health Insurance Exchange, Medicare and FEHBP will be rewarded for achieving performance thresholds on outcome measures.

This is more of the mindset that got us HMOs.

3. Comparative effectiveness research. Obama will establish an independent institute to guide reviews and research on comparative effectiveness, so that Americans and their doctors will have the accurate and objective information they need to make the best decisions for their health and well-being.

Ah, the politicization of science. I guess the only time that’s bad is when George Bush does it.

4. Tackle disparities in health care. Obama will tackle the root causes of health disparities by addressing differences in access to health coverage and promoting prevention and public health, both of which play a major role in addressing disparities. He will also challenge the medical system to eliminate inequities in health care through quality measurement and reporting, implementation of effective interventions such as patient navigation programs, and diversification of the health workforce.

So some people don’t get good health care because “people like us” aren’t the ones in the health workforce? And that problem is going to be solved by paperwork and bureaucratization?

5. Insurance reform. Obama will strengthen antitrust laws to prevent insurers from overcharging physicians for their malpractice insurance and will promote new models for addressing errors that improve patient safety, strengthen the doctor-patient relationship and reduce the need for malpractice suits.

Right. “Overcharging.” First the government drives malpractice insurers out of the business, then complains that there aren’t enough of them, so it’s going to control the monopolistic prices they can charge. I can see investors lining up now to put their money into insurance providers regulated by Obama.

And there is so much more in this one that deserves to be mocked, but so little time…

* Lowering Costs Through Investment in Electronic Health Information Technology Systems: Most medical records are still stored on paper, which makes it hard to coordinate care, measure quality or reduce medical errors and which costs twice as much as electronic claims. Obama will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records, and will phase in requirements for full implementation of health IT. Obama will ensure that patients’ privacy is protected.

Yup. More of the sort of thing that discourages ïntegration” of health care. We complain all the time about how insurers are interested only in the bottom line. If this sort of thing was really where cost-savings are going to be realized, wouldn’t insurers do it on their own without the gentle, guiding hand of Obama?

* Lowering Costs by Increasing Competition in the Insurance and Drug Markets: The insurance business today is dominated by a small group of large companies that has been gobbling up their rivals. There have been over 400 health care mergers in the last 10 years, and just two companies dominate a full third of the national market. These changes were supposed to make the industry more efficient, but instead premiums have skyrocketed by over 87 percent.

Pharmaceutical companies have consolidated over the years, with the winners being not the ones who do the best work in developing new drugs, but the ones who can best schmooze the regulators. With more Obama-regulation, such consolidation will only continue until there is only one insurer — the government. Then we’ll have all the worst aspects of our current system, only on a grander scale.

1. Barack Obama will prevent companies from abusing their monopoly power through unjustified price increases. His plan will force insurers to pay out a reasonable share of their premiums for patient care instead of keeping exorbitant amounts for profits and administration. His new National Health Exchange will help increase competition by insurers.

This is going to be great, allowing bureaucrats to decide what’s “unjustified” and what’s “exorbitant”. More corruption.

2. Lower prescription drug costs. The second-fastest growing type of health expenses is prescription drugs. Pharmaceutical companies are selling the exact same drugs in Europe and Canada but charging Americans more than double the price. Obama will allow Americans to buy their medicines from other developed countries if the drugs are safe and prices are lower outside the U.S. Obama will also repeal the ban that prevents the government from negotiating with drug companies, which could result in savings as high as $30 billion. Finally, Obama will work to increase the use of generic drugs in Medicare, Medicaid, and FEHBP and prohibit big name drug companies from keeping generics out of markets.

I’ve seen how these big buyer cooperatives work on smaller scale. What it usually means is buyer and vendor work out a deal, and the customer is screwed if s/he is required to purchase through that system.

Joe Klein gets it

 Health care reform  No Responses »
Apr 112008
 

I’ve been arguing for some time that the hubris that took George Bush to war in Iraq is similar to the hubris by which the left thinks it can come up with a nationalized health care plan that will work. In both cases, the proponents are without a clear plan for what to do once the conquest is complete. They just tell us that surely there has got to be some way to do it.

The people I’ve mentioned this to act like they don’t know what I’m talking about. But Joel Klein gets it. He understands the similarities. He thinks his version is better than the Bush version, but he gets it:

I didn’t question the patriotism of conservatives: I simply argued that it is more patriotic to be optimistic about the chance that our collective will–that is, the best work of government–will succeed, rather than that it will fail or impinge on freedom.

Gulag hospitals

 Health care reform, Russia  No Responses »
Mar 182008
 

I’m still reading Anne Applebaum’s book. One thing that is new to me is how the gulag hospitals were in some places very nice — a completely different world from the prison camp for those prisoners unfortunate enough to be fortunate enough to be sent to them.

“Paradise” is what Evgeniya Ginzburg called the hospital where she worked in Kolyma. “We felt like kings,” wrote Thomas Sgovio of the “recovery barracks” in the Srednikan lagpunkt, where he received a “fresh, sweet roll in the morning.” Others write with remembered awe of the clean sheets, of the kindness of nurses, of the lengths to which doctors went to save their patients.

Of course, they weren’t all like this. Some were filthy, overcrowded death-traps. But it’s interesting that some were.

The problem was that there was usually some sort of quota system that allowed only a certain number of patients to be admitted to them each day. In the meantime, other prisoners were dying from disease, overwork, abuse, and malnutrition outside the hospital. And doctors sometimes had to reserve a few hospital slots for the criminal prisoners who terrorized the camps, which meant even less were available for the prisoners who really needed them.

UK’s Czarist Justice

 Health care reform, Russia, Welfare-police state  No Responses »
Mar 092008
 

I’m currently reading Anne Applebaum’s “Gulag : A history” (2003). In the introduction is a section about pre-Soviet times, which tells about an earlier version of Soviet justice.

The practice of exiling people who simply didn’t fit in continued throughout the nineteenth century. In his book, Siberia and the Exile System, George Kennan–uncle of the American statesman–described the system of “administrative process” that he observed in Russia in 1891:

The obnoxious person may not be guilty of any crime…but if, in the opinion of the local authorities, his presence in a particular place is ‘prejudicial to public order’ or ‘incompatible with public tranquility,’ he may be arrested without warrant, may be held from two weeks to two years in prison, and may then be removed by force to any other place within the limits of the empire and there be put under police surveillance for a period of from one to ten years.

And now that type of justice is coming to the west. Great Britain now has “Anti-Social Behaviour Ordinances” by which that country has casually tossed aside a thousand years of progress in the rule of law.

Consider the information on the web at scotland.shelter.org.uk:

The law says that someone is behaving in an antisocial manner if:

* they are acting in a manner that is causing, or is likely to cause, alarm or distress, or
* they are doing several things over a period of time that cause, or are likely to cause, alarm or distress to at least one person living in another household.

This definition also covers verbal abuse, so if someone has been shouting and swearing at you or even saying things which make you and others feel uneasy, then it could be classed as antisocial behaviour under the law.

Whatever the problem is, it has to have happened more than once to at least one person. If it’s an isolated incident, it won’t count as antisocial behaviour, although there may be other things you can do to solve the problem, such as getting an interdict from a court

You don’t have to be guilty of any crime, you only need to be doing something the local authorities don’t like. It’s a rather arbitrary power. There is an appeals process, and the power isn’t supposed to be completely arbitrary, but words like “alarm,” “distress,” and “feel uneasy” can cover just about anything.

Why do I care what the Brits are doing? Well, we seem to be following in their path to a welfare-police state. That’s what a lot of Americans are counting on the coming elections to do for us. I am not sure how something like this cannot come here in the aftermath.

George McGovern for President!

 Free markets, Health care reform, Regulation  1 Response »
Mar 072008
 

Where can I get a George McGovern for President bumper sticker? I didn’t have one on my car back in 1972 (I’m not sure my wife would have approved) but I was a McGovern supporter back then.

Well, mostly I was against Nixon and Watergate, but I was suffering from a bout of leftwingism, too. I got over it in time for the 1976 elections, though suffered some lingering symptoms until Ronald Reagan’s first year in office.

But here is George McGovern at the WSJ, sounding like the type of libertarian-leaning Republican that could make me become a Republican again:

…Under the guise of protecting us from ourselves, the right and the left are becoming ever more aggressive in regulating behavior…

…There’s no question, however, that delinquency and default rates are far too high. But some of this is due to bad investment decisions by real-estate speculators. These losses are not unlike the risks taken every day in the stock market….

…Health-care paternalism creates another problem that’s rarely mentioned: Many people can’t afford the gold-plated health plans that are the only options available in their states.

Buying health insurance on the Internet and across state lines, where less expensive plans may be available, is prohibited by many state insurance commissions. Despite being able to buy car or home insurance with a mouse click, some state governments require their approved plans for purchase or none at all. It’s as if states dictated that you had to buy a Mercedes or no car at all.

Economic paternalism takes its newest form with the campaign against short-term small loans, commonly known as “payday lending.” …

…Anguished at the fact that payday lending isn’t perfect, some people would outlaw the service entirely, or cap fees at such low levels that no lender will provide the service. Anyone who’s familiar with the law of unintended consequences should be able to guess what happens next.

Researchers from the Federal Reserve Bank of New York went one step further and laid the data out: Payday lending bans simply push low-income borrowers into less pleasant options, including increased rates of bankruptcy. Net result: After a lending ban, the consumer has the same amount of debt but fewer ways to manage it.

Since leaving office I’ve written about public policy from a new perspective: outside looking in. I’ve come to realize that protecting freedom of choice in our everyday lives is essential to maintaining a healthy civil society.

Why do we think we are helping adult consumers by taking away their options? We don’t take away cars because we don’t like some people speeding. We allow state lotteries despite knowing some people are betting their grocery money. Everyone is exposed to economic risks of some kind. But we don’t operate mindlessly in trying to smooth out every theoretical wrinkle in life.

The nature of freedom of choice is that some people will misuse their responsibility and hurt themselves in the process. We should do our best to educate them, but without diminishing choice for everyone else.

I’ve been wondering what to do with my vote on election day. Now I think I know. I’ll write in George McGovern’s name!

Faith in the Operating Room

 Health care reform  No Responses »
Feb 282008
 

A Jehovah’s Witness patient needs an operation, but warns the surgeon that he absolutely does not want a blood transfusion. The operation is one that might come off without the need for blood, but not necessarily. What’s a surgeon to do?

I can see why the surgeon would have problems doing an operation in which he’s not allowed to use all the tools of the trade to keep the patient from dying. The surgeon did the operation, and just barely escaped the need for a transfusion. But what about next time?

This New York Times article tells the story. Some of us would say difficult issues like this are why we need a separation between Health Care and State. There are difficult ethical choices to be made on both sides, and there is nothing the government as health care provider can do that would not make the situation worse.

But it’s interesting to read the comments that follow the article. There are some thoughtful reactions, but also some that suggest a whole lot of people out there are not thinking in terms of how to maximimize individual choice and freedom.

Real ID and health care

 Health care reform, Human rights  No Responses »
Feb 082008
 

The real problem with nationalized health care is not that it will decrease the quality of health care and raise costs, though it will do that, judging by how it has worked everywhere it has been tried. But some people are willing to accept that, in exchange for the benefits.

No, the real problem is the threat to civil liberties. Here is an example of how it makes a tempting kudgel for the government to use to keep people in line:

WHEN THE Department of Homeland Security came out with the final REAL ID regulations last month, a top official threw the department’s final Hail Mary, suggesting that REAL ID could be used to control access to cold medicine. That’s right: cold medicine. The lesson? Once a national ID system is in place, the federal government will use it for tighter and tighter control of every American.

This quote is from an article in The American Spectator by Jim Harper of the Cato Institute. Here’s another:

REAL ID isn’t about national security. It isn’t about illegal immigration. It isn’t about identity fraud, or even cold medicine. It’s about Washington politics. Federal bureaucrats want to coerce states like Virginia into building a multi-billion dollar system for identifying, tracking, and controlling law-abiding citizens.

And of course, one could make a very similar statement about nationalized health care.

Boston Puritans oppose cheap, accessible health care

 Health care reform  No Responses »
Jan 122008
 

From the Boston Globe. It looks like the Boston Puritans are scared to death that people might learn there can exist such a thing as free markets for even a tiny fraction of health care issues. Once people learn about that, who knows where it might lead? It could mess up their plans for a system of pure, total control by government (aka Puritan Totalitarianism). In fact, one of the board members said as much, using leftist code words:

Dr. Paula Johnson, a board member and physician at Brigham and
Women’s Hospital, said episodic visits to a drug store clinic could
defeat efforts to provide patients with a reliable continuum of care. “We could be setting ourselves up for some real problems,” she said.

Menino decries clinics in retailers : Urges health council to bar infirmaries from opening in city
By Stephen Smith, Globe Staff / January 11, 2008

Bob Lewis

 Free markets, Health care reform, Limits on government power  No Responses »
Nov 172007
 

My favorite IT pundit is Bob Lewis, who has an Advice Line blog at Infoworld. I’ve been reading him for years, since long before there were such things as blogs. (I liked Bob Metcalfe, too, as an IT pundit, back when he was punditing. But now that he’s gone, it’s just Bob Lewis.)

Before he got into IT, Bob got a PhD doing behavioral research on electric eels, which means he got off to a good start. He has amazing insights into the way businesses can and should work, especially but not only on the IT side. Anyone who believes in the conservative values of free markets and limited government will find a wealth of information to help one understand why we do not want the usual leftwing solutions of centralized planning and welfare-police statism.

Unfortunately, Bob has not allowed his business insights to inform his politics. He leans way too far to the left in politics, and often acts like a frustrated political pundit who looks for any excuse to talk politics rather than business. He draws connections between business and politics, sure enough, but is usually oblivious to the real import of what he is saying. Some people find his politics annoying. But that’s no reason not to read his columns and use them as a valuable resource for libertarian-leaning conservative politics.

Here is an example, from his latest, titled “The magic formula for IT budgeting.”

I know practitioners who claim it allows them to estimate projects with high levels of precision.

My personal opinion: The best way to estimate projects is to break them into small chunks with go/no-go gates in between. That allows you to avoid estimating how long it will take to build a system before you’ve decided what has to go into it.

That’s a great argument for not letting the government design a massive health care system for our country, which if it was to work would require knowledge that no government bureaucracy could ever hope to attain.

An alternative, which I increasingly like as I grow older and less energetic, is to assign one programmer/analyst to a business change effort. The P/A sits with the end-users, learns their job, helps them think about the next logical and easy-to-implement process improvement, and makes whatever system changes are necessary to make it possible. Then they do the next one.

It’s business improvement through the removal of small annoyances. It can be surprisingly effective, and makes resource planning easy. What it doesn’t let you do easily is predict when you’ll reach the point of diminishing returns on the improvement effort so you can redeploy your P/A to the next one.

Exactly. Whether it’s transportation planning or health care reform, nothing can beat the use of the market to let people design solutions to remove small annoyances. Of course, that doesn’t feed political egos, so government has no natural motive to nurture, protect, and foster these market forces. Instead, it tries to force private parties into government-like one-size-fits-all mandates (e.g. mandated benefits) where they will naturally fail, which will give government an excuse and political support to step in, take over, and make the situation even worse. But we shouldn’t be buffaloed when they say, “Well, what is YOUR solution?” There is no one solution — probably no solution at all. There is just the ability to improve our health care system greatly through small, market-oriented reforms. That doesn’t mean there is no place or need for government welfare — just that we do not want it for a solution.

Bob also publishes a column called “Keep The Joint Running” at issurvivor.com Highly recommended. Bob dislikes conservative politics, but that doesn’t matter. His column is one of the best conservative resources out there now that Milton Friedman is gone.

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