31 August 2009

Medical Professionals and Torture

According to a report from Physicians for Human Rights, doctors and mental health professionals were rather more involved in the US torture program than previously thought:

PHR Analysis: CIA Health Professionals’ Role in Torture Worse Than Previously Known
Cambridge, MA — The extent to which American physicians and psychologists violated human rights and betrayed the ethical standards of their professions by designing, implementing, and legitimizing a worldwide torture program is greater than previously known, according to a report by Physicians for Human Rights (PHR).[...]

The required presence of health professionals did not make interrogation methods safer, but sanitized their use, escalated abuse, and placed doctors and psychologists in the untenable position of calibrating harm rather than serving as protectors and healers. The fact that psychologists went beyond monitoring, and actually designed and implemented these abuses – while simultaneously serving as 'safety monitors' – reveals the ethical bankruptcy of the entire program,
It's long disgusted me that American public servants were authorized to torture during the Bush administration.  It's not surprising but no less disturbing to find out that there were doctors, sworn to heal, taking part in these sessions.

This is Dr. Josef Mengele. He is rightly remembered with loathing by all members of the medical profession. He has become the symbol of the medical professional corrupted by power, the apostate healer who abandoned the Hippocratic oath.   It would be wrong to equate the American physicians who monitored the prisoners being tortured under President Bush with Dr Mengele; his crimes and depravity were far worse.  Yet they are his modern-day brethren, and the comparison is apt. 

Bear in mind: physicians have an ethical obligation not to take part in practices which harm.  It's not an accident of history that doctors are ethically forbidden to assist in executions.  That some do participate in judicial executions is a matter for their own consciences, they are generally cloaked in anonymity and shielded from public view.  And so it likely shall be for the physicians who participated in President Bush's torture program; the likelihood of accountability seems low.  But the public position of the profession of medicine is clear: doctors are medical professionals and dedicated to helping their charges. To take part in activities intended to hurt or to kill is beyond the pale and shameful in the extreme, and cannot be condoned in any way.

ER doc to run for Oregon Governor (again)

Kitzhaber bid for governor seems likely
SALEM, Ore. (AP) - Speculation is mounting that former Democratic Gov. John Kitzhaber will announce this week he's going to run for an unprecedented third term as Oregon's top leader.

Kitzhaber is keeping mum for now, but friends believe he's ready to jump in.

One of them - former state Senator Tony Corcoran - says Kitzhaber remains extremely popular with Oregon Democrats who are excited about the prospect of him becoming Oregon's governor again.

Kitzhaber is a former emergency room physician and state legislator. He made his mark in the governor's office as a defender of the environment and an advocate for expanded health care.
I can't attest as to whether he was a good governor or not, but I've heard him speak on health care reform and came away very impressed. 

Universal Health Care for Malpractice Reform

Bill Bradley talks some sense, echoing my thoughts from two weeks ago. (I am so prescient I can't stand it!)

Op-Ed Contributor - Tax Reform’s Lesson for Health Care Reform - NYTimes.com
I believe such a grand bipartisan compromise is still possible with health care.

Since the days of Harry Truman, Democrats have wanted universal health coverage, believing that if other industrialized countries can achieve it, surely the United States can. For Democrats, universal coverage speaks to America’s sense of decency and compassion. Democrats also believe that it will lead to a healthier and more productive country.

Since the days of Ronald Reagan, Republicans have wanted legal reform, believing that our economic competitiveness is being shackled by the billions we spend annually on tort costs; an estimated 10 cents of every health care dollar paid by individuals and companies goes for litigation and defensive medicine. For Republicans, tort reform and its health care analogue, malpractice reform, speak to the goal of stronger economic growth and lower costs.

The bipartisan trade-off in a viable health care bill is obvious: Combine universal coverage with malpractice tort reform in health care.

Universal coverage can be obtained in many ways — including the so-called public option. Malpractice tort reform can be something as commonsensical as the establishment of medical courts — similar to bankruptcy or admiralty courts — with special judges to make determinations in cases brought by parties claiming injury. Such a bipartisan outcome would lower health care costs, reduce errors (doctors and nurses often don’t report errors for fear of being sued) and guarantee all Americans adequate health care.
I'm not optimistic, for the reason Ezra points out: the GOP has made opposition to reform their strategy.  Were the democrats to offer them such a deal, which they have hinted at, it would be moot since it appears that vitriolic opposition (in the setting of shameful demagoguery) is viewed as the path back to power in 2010 for the GOP.   A "deal" presupposes that there are two parties that want a deal, and that does not seem to be the case at this time.  Pity, since I think malpractice reform plus health care reform would actually result in a better outcome than the Dems' going it alone.

Now I guess we'll get to see whether the Democrats possess sufficient parliamentary and political acumen to shepherd a bill through strictly along partisan lines.  History does not teach me to be optimistic on this point either.

29 August 2009

Saturday Linking

I'm finding it striking that two of the best storytellers in the medical blogosphere are surgeons.

Buckeye Surgeon: Further Tales from the Nonagenarian Archives
When I walked in her room, the first thing she said was "who the hell are you", in this thick, eastern european accent. She seemed pretty sharp though. She sat upright in bed, meticulously feeding herself some soupy hospital-issue scrambled eggs (yeah, not sure why she was on a regular diet). Her eyes were vigilant and focused, darting right and left
other things amanzi: sacred memories
when i got accepted into medicine as a last minute add-on due to one of their other applicants turning down the post, i knew how lucky and privileged i was. it was the first step in a very long journey and i wasn't going to mess it up.
I thought surgeons were supposed to be dull-witted, hyper-aggressive macho blockheads.  Quit messing with my prejudices, guys!

Also, Dr LaPook takes a look at cancer funding:

Better Health » Cancer Needs A Bailout
The annual budget of the National Cancer Institute (NCI) is just under $5 billion.  With over 560,000 cancer deaths each year, that comes to less than $10,000 in research spent for every cancer death. That simply is not enough money spent on a problem that strikes almost 1.5 million Americans each year and causes nearly one of four deaths.
Research for certain cancers is especially under funded.
I'll add as an aside that funding for pediatric cancers is particularly short.

28 August 2009

Government-run health insurance

Explained via cute cartoons:

via watertiger

26 August 2009

Kennedy Debates Health Care Reform

In 1971!

The more things change...

There's an app for that

Of course, maybe there shouldn't be:

Monkey See, Monkey Do

File this under utterly predictable:

Aetna tightens payment policies on hospital errors - Modern Healthcare (sub req)
Aetna has established new, tighter policies dictating when it will and will not reimburse for medical care related to errors made by providers.

Under the policies, Aetna has broken errors into two categories: “never events”—three events involving surgery: wrong patient, wrong site and wrong procedure—and 25 serious reportable events as defined by the National Quality Forum. Providers will not be reimbursed for a case involving one of the three never events, under the new payment policy. Of the 25 events, eight will be reviewed by Aetna to determine whether reimbursement should be withheld. The rest of the events will also be reviewed under Aetna's new policy, but they will not be considered eligible for adjustments to reimbursement, the spokeswoman said.

This of course follows on the heels of Medicare's decision not to pay for such events. The good news is that, as far as I can tell, Aetna has not extended the policy as far as Medicare has. Medicare, you may recall, also decided not to pay for certain (arguably) preventable conditions, such as foley-catheter-associated urinary tract infections, and surgical wound infections. Aetna, at least for the moment, is limiting its policy to the more black-and-white "never events" as defined by the National Quality Forum: items such as wrong-patient surgery or death due to contaminated medications.

I mention this not to rail against these standards or against the notion of incentivizing hospitals financially to avoid errors, but to highlight how rapidly and directly Medicare policies are aped by private insurers to the point that they become industry standards.

25 August 2009

The Last Brother Passes

RIP, Teddy

23 August 2009

Sunday Funny

via Orac

This sat in my "starred" file for a week, and I'm really glad I got around to watching it:

21 August 2009

It's funny because it makes no sense

From WaterTiger:

A special message to all the "ZOMG, health care reform will KILL MY GRANDMA and give Cadillacs to welfare queens and take away our guns an' shit!", I've got something to say to you:

The most respected man in journalism

Jon Stewart goes toe to toe with professional liar Betsy McCaughey.  It's painful to watch, seriously painful.  My wife is wondering why I keep shouting at the computer.  I wish more people took her on as directly as Stewart does.  Best line: "I like you, but I don't understand how your brain works."

The Daily Show With Jon StewartMon - Thurs 11p / 10c
Intro - Pull the Plug
Daily Show
Full Episodes
Political HumorHealthcare Protests

Part One

The Daily Show With Jon StewartMon - Thurs 11p / 10c
Exclusive - Betsy McCaughey Extended Interview Pt. 1
Daily Show
Full Episodes
Political HumorHealthcare Protests

Part Two

The Daily Show With Jon StewartMon - Thurs 11p / 10c
Exclusive - Betsy McCaughey Extended Interview Pt. 2

Daily Show
Full Episodes
Political HumorHealthcare Protests

* Yes, the "Most respected man in Journalism" comes from an internet poll, but it's kinda sad when Stewart really is the most willing to call bullshit on these scaremongers

AHIP takes a shot at physicians

AHIP, the trade group representing the nation's health insurers, released a study decrying excessive physician charges.  There's some amazing stuff in there: office visits being billed at $6200, a lap chole being billed at $9,000 (just for the physician's portion).  Truly egregious, if true -- and that's the qualifier.

The methodology of this "survey" is not really honest.  They cherry-picked an insurance database looking for the highest billed charges for various CPT codes.  Supposedly they "excluded high charge outliers that may reflect billing or coding errors."   Really?  How on earth, one wonders, could they have concluded that an office visit billed at 5,000% the medicare rate was not an error?  Were there more outrageous charges that were excluded?  Sounds fishy.

Moreover, the survey is promoted as exposing the outrageous fees that doctors charge, when in no way are these fees representative of physician fees.  Physician fees, as any other group of data points, fall into a more-or-less normal distribution.  There's a median point around which most practices cluster, and the further out you get the fewer physicians that are charging those fees, high or low.  The cited fees are certainly in the 3+ standard deviation tail of this graph, but you wouldn't know it from the AHIP press release.

They present these outrageous charges as if they are accurate and as if they represented a widespread abuse of consumers by greedy doctors.  

The annoying thing about this is that there is a valid argument to be made that the uninsured do face higher fees than the insured.  This is of course more of a factor with the much-higher hospital costs, but physician fees are also higher for the uninsured.  The reason for this is that insurers demand a discount off the standard fee in order to contract with physicians.  This gives physicians an incentive to crank up their fee schedule as high as they can get away with.  So if UnitedHealth comes to me and offers to pay me 75% of billed charges (I wish!), I need to make sure that my fee schedule puts that figure at a level that is going to return a reasonable per-patient compensation.   This is less of an issue nowadays, since most insurers prefer to settle on a conversion factor and contract by the RVU, or as a percentage of the standard medicare rates (110-150% most commonly).  That's easier for their billing systems to manage.  So there is less incentive for us to keep charges high.  But still, a few insurance plans like to do the old way, and there are occasional patients who are insured but we don't have a contract with their insurer.  In those cases, we expect compensation in full, and the insurer usually pays some arbitrary sum that they feel is reasonable, with the patient responsible for the balance.    

Does this screw the folks without insurance?  Yes, to a degree.  Most of the uninsured don't pay a dime.  They just throw out the doctor's bill, along with the much-bigger hospital bill, and we wind up writing it off as bad debt.  Most hospitals, and our practice, will also write it off as charity if the patient asks for it and can show some hardship.  So the uninsured will get a huge bill, but they very very rarely have to pay a huge bill.

The ultimate solution for this "problem" of the uninsured being "overcharged" is not, as AHIP implies, to somehow regulate physician charges, but to eliminate the uninsured.  Get everybody covered under some sort of insurance plan, and this problem goes away.


Graham linked to this at The Central Line, but it's worth retweeting:


Hysterical short videos on common minor ED procedures.  My favorite is "Penis-thesia."

Plus ça change, plus c’est pareil

Tom Tomorrow cites an op-ed against health care reform. Key graf:

The State and Moral Power
US health is probably not as good as the AMA's Dr Fishbein says it is. But it is good enough in comparison to that of the British, French, Germans, Danes, Dutch, and New Zealanders to establish a reasonable presumption that voluntary methods work as well or better than compulsion of one sort of another by the state. This does not mean that some 30 million Americans who cannot afford a doctor should be left to suffer in silence. Public hospital services, free or partly free, are an established part of the American scene, and no stigma of "charity" attaches to them.

Of course, this op-ed was published in Life magazine in 1949, arguing against President Truman's national health insurance program. Change the names, and it could have been published today.

I take that back, the tone of this op-ed is far more serious and far less scaremongering than the typical modern op-ed.

Here's the whole thing (click to embiggen)

20 August 2009

In defense of Press-Ganey

Boy, if there's one thing that ER docs are coming to hate, it's Press-Ganey.  The tales of its misuse by poorly informed managers are legion.  Dr Brenner had another frustrating one yesterday : Dr. Brenner's Thoughts on Healthcare: My own private Press-Ganey Hell
I started a new job in January, and from the get-go had great PG scores. Of course, the sampling was low, so nothing was statistically significant. Once I got one unhappy patient, it killed my score. So 4 excellent scores and 1 bad one = Very bad PG score. But despite that, my scores were still in the top 80%. And stayed that way until June.

All of a sudden, in June my scores dropped to 1%. I naturally assumed I must have gotten a bunch of really bad reviews. Bad luck? Bad day for me? I didn't know. We have a binder that has the recent PG reviews for the department, and looking in there, all the reviews were 5's. The highest. I didn't get it.

The inevitable happened. My administrator saw my scores and insisted I be rehabilitated.
Boy, that's painful.  And I won't reveal the kicker, but it gets worse.  So whose fault is this?  Is it the fault of Press-Ganey?  Well, maybe.  Data collection is a finicky business, and the results are only as good as the process that brings them forth.  But I would contend that the fault lies not in the data itself, but in that of her medical director and hospital administration, who seem to be afflicted with that common disease of statistical innumeracy.  Can an "n" of five give valid information on an individual practitioner?  Of course not!  It's stupidity itself to try to break down the results to such a level of detail with such a low sampling model.

We use P-G ourselves, and with 110,000 visits and a relatively high sampling ratio, we still don't get enough information on each doc to provide meaningful practitioner-level ratings.  We distribute them, for informational purposes, but we don't use them in any way at that level.  There's been talk about incentivizing docs to provide exceptional service by incorporating P-G into the compensation system somehow.  I'm a huge believer in the theory that you get the behavior that you incentivize, so I am interested in the notion.  But it's a ludicrous impossibility without cleaner, more valid data that quite honestly does not exist.

There's a clear sentiment in Dr Brenner's post, as well as the rantings of multiple other ER bloggers out there, that the whole notion of "patient satisfaction" is wrongheaded and perverse.  For example: How Press-Ganey is changing medicine
I've always practiced that educating your patients in the ER is the best medicine. Whether on nutrition or the nature of their disease process, my patients always appreciate it. Or so I thought. Now I'm being told that my patients don't want to hear that. They don't want to be told to quit smoking. [...] They want that prescription for a z-pack. They want their vicodin. They want that head CT or that MRI and especially that foot xray for that stubbed toe.
Sorta.  I agree that patient's agendas when they come to the ER can be ill-informed, and we make it clear to our ER docs that we do not want them handing out inappropriate prescriptions (etc), and that we will back them up if we receive patient complaints that pertain to that sort of thing.  However, when you look at P-G feedback in large quantities, the typical complaints or illustrative comments reveal that other factors are the critical elements in patient dissatisfaction.  I've reviewed hundreds, if not thousands of these comments, and several themes have emerged that provide very useful information on how we can serve out patients better.

To answer the question: What are the key drivers of patient satisfaction?  These elements seem to matter most:
  • Patients want to be placed in the treatment area promptly and seen by a provider in a timely manner.
  • Patients want their doctors and their nurses to be polite and respectful.
  • Patients want to feel that their physician listened to them.
  • Patients want to feel like their caregivers cared about their comfort.
I don't think there's anything controversial on that list.  But how do you use it?  You design processes and procedures that reflect the patients' priorities as well as the medical necessities of the ER.

The Bed-to-door time and door-to-doc times correlate dramatically with the top-level "likelihood to recommend" patient satisfaction score.   Patients hate waiting, and I do too, when I have been a patient.  Further, this is not an unreasonable expectation on the part of patients.  If the wait times are averaging an hour or more, then your ER is underperforming (dramatically) in this arena and it's predictable that the P-G numbers will reflect that.  Whole books have been written about optimizing ER patient flow, so I'll not belabor the point.  Still it must be noted that this alone is probably the single most important factor in overall satisfaction. 

The other elements relate more to the human factor: how does your staff interact with patients?  It's pointless and wrongheaded to single out and stigmatize individual providers for "failing" their P-G, but it is useful and productive to emphasize to all the staff, from Doctors to Unit Clerks and Registrars, that these factors matter, and that patient satisfaction is important.  Providing education and reinforcement to all staffers for such things as "active listening" techniques, developing scripts to standardize certain communications, and teaching your staff what sort of things patients tell us they care about all are fundamental to improving your department's scores.

Remember that when patients talk about their "comfort" that they are not necessarily talking about narcotics.  That's a common assumption in this age of frequent fliers and drug-seekers.  To the average patient, the ER is a bewildering and uncomfortable place to be.  Little things like getting the patient a warm blanket, a pillow, pulling the curtain for their privacy, or finding a chair for their family member are incredibly important to patients.  Telling them your name, or reminding them of their doctor's name.  Again, when you train your staff in these things, when you let them know that they matter and you get buy-in from the caregivers in the ER, then you start to see cultures change, and scores improve.

How do I know this?  We've lived it.  A number of years ago, I'm not proud to say that our ER was the worst in the nation in P-G scores: the 1st percentile.  Rock bottom.  Nothing like sitting down with your CEO and explaining why you're the worst ER in the whole country to give you some incentive to improve.  So we set about a comprehensive improvement project.  It has taken years, but we've turned the corner.  It also takes partnering with the hospital administration.  There may be a need for additional resources: If the ER is so understaffed that nurses can barely provide safe patient care, it's going to be hard for them to spend time getting warm blankets.  If half the beds are full of boarded patients, then wait times will remain long and scores will never improve.  And so on.  And it also takes an understanding of how to read and how to use the data.  A few years back, we hired a doc whose individual P-G scores at his old hospital were always in the 99th percentile.  When he came to us, his scores plummeted to near our physicians' group average.  The moral to that it that it's the institution as much or more than the individual that determines how a provider will be ranked.

"You can't manage what you can't measure," is the old management aphorism.  P-G is imperfect in many ways.  But it's a useful yardstick for comparing one ER to another, and more importantly for comparing your ER today to your ER last year.   Ultimately, Press-Ganey is just a tool, one among many.  It can be used well, poorly, or not at all.  My experience, from a management perspective, is that it can be a valuable part of an overall process improvement initiative in the ER. 

Look, ma! No hands!

As an ER doc, I'd be remiss not to point out that it's perfectly OK for you to try this at home as long as you are wearing a helmet.

What a strange and wonderful world we live in.  I liked the soft music, somewhere in between ballet or figure skating.  I've seen bike routines in the US and they were all more "urban" and had hip-hop soundtracks, which was irritating.

19 August 2009

I got nothing

Enjoy these pictures of the Supermarine Spitfire:

It"s cool to see them in color.  Can't recall seeing them on a carrier before, either.

Source:  Life Magazine

18 August 2009

This is cool

What killed Mozart?
Mozart’s sister-in-law, the authors note, said that his body became so swollen during his fatal illness that he could not turn in bed. His cause of death in a Viennese death registry was “hitziges Frieselfieber,” or fever and rash.

But all of these things — swelling, fever, rash — are symptoms that don’t tell us what the underlying disease was. Speculation since the time of Mozart’s death has ranged from poisoning, to syphilis, to trichinosis from eating undercooked pork chops.

Whip Count

There was a lot of noise over the weekend about whether or not the Public Plan was "dead."  The fuel for this was the comments made by Obama and Sebelius which downplayed the public option as only one facet of reform, but the spark seems to have come from Conservadem Kent Conrad, who keeps insisting to anybody who will listen that the public plan "doesn't have the votes" to pass the Senate.

As an aside, it really annoys me that Conrad says this over and over to journalists, yet none of them ever ask him "Will you personally join a filibuster of health reform if it contains a public plan?"  This way Conrad gets to pretend he's just counting the votes, when really this sounds like an implied threat that he would filibuster if his demands aren't met.  But anyways.

The sad truth is that I think he's right, but maybe not for the reason he implies.  I suspect -- it's so hard to say -- that if the Senate ultimately has to vote on a bill with the public option, there will not be any democrats willing to filibuster a democratic President's signature policy issue.  This assumes that we can force them to take a firm stance on an extant, final bill.  The way we get there is that the Senate passes a bill with a weak public option or co-ops, the House passes a stronger public option, and the conference committee returns a bill to both chambers with some sort of public option.  At this stage the bill can be filibustered, or they can vote "nay," but it cannot be amended.

So all the Democrats need to do is enforce party unity for the final cloture vote -- a tall order but not impossible -- ram the bill through with 60 democratic votes and we win, right?

Unfortunately not.   I hate to say this -- I really hate to say this -- but there's a strong chance that the Dems may only have 59 votes.  Teddy Kennedy is gravely ill.  So ill that he was unable to attend the funeral of his sister.  He has not been seen in public for some months.  Will he be able to come back to DC for one final vote in the Senate?  What a scene that would be!  59-40, Kennedy wheels in to thunderous applause and raises his hand and whispers "Aye," propelling his career's quest for universal health care to victory!  It would be a made for Hollywood moment.  We can hope, but it's sounding increasingly farfetched.

Without Kennedy, the situation changes dramatically.  In order to achieve cloture on the final bill, you need party unity plus a republican, which is a very different matter.  Snowe or Collins are possibilities, but would they be willing to break party ranks on such a high-profile matter?  I don't know.  Unless a deal can be struck behind the scenes for their support, it would be a bold step to bring a bill with a public option out of conference committee.

With so much we don't know, and so much time to go, there's little point in counting the votes just yet.  But from what we do know, I have to say that the odds of a public plan being in the final product get longer every day.

17 August 2009

I like flow charts

This may be a bit late, since the public plan may well be in the ICU on comfort care, but, via Ezra, here's a nice flow chart of how the health insurance reforms would actually look, in terms of relative impact:

Created by Nicholas Beaudrot

16 August 2009

Man pulls gun in ER, killed by police

Patient shot dead by police at Olympia hospital | KOMO News - Seattle, Washington | News
OLYMPIA, Wash. - An unruly patient at an Olympia hospital was shot dead by a police officer early Saturday when the patient pulled out a gun in an emergency treatment room, officers said.

The bizarre incident began at about 2:15 a.m. Saturday when the security staff at Providence St. Peter Hospital called police to ask for help in dealing with an unruly, 220-pound patient who was possibly armed. [...] The officers searched the man, identified as Joseph Leonard Burkett, and found two loaded handguns. The guns were confiscated, and officers later discovered they had been stolen from a home in McCleary.

About two hours later, Burkett was scheduled for a medical test, but when hospital staff began to get him ready for the test, he again became agitated and unruly, police said.

The officer who was on guard entered the treatment room to assist the emergency room staff. When he did, Burkett pulled out yet another gun.

The officer and Burkett wrestled for the weapon. During the struggle, the officer fired one shot at the patient.

Hospital staff immediately began treating Burkett for the gunshot wound, but they were unable to save him. He died there in the treatment room.
Yikes!   (h/t Gruntdoc)

As good a time as any to repost this as a reminder:

Always logroll your trauma patients.

15 August 2009

One-man Death Panel

TNR's Jon Cohn gets a laugh out of Stephen Colbert:

The Colbert ReportMon - Thurs 11:30pm / 10:30c
Jonathan Cohn
Colbert Report Full EpisodesPolitical HumorMeryl Streep

Deep thought

If you have a pathological aversion to water, the sight of which causes severe panic attacks, then:

A) The US Navy might not be the ideal career choice for you
B) Being stationed on a destroyer is going to be a very challenging deployment

Just saying.

The art of compromise

Economic View - A Public Option Isn’t a Curse, or a Cure - NYTimes.com
To the Republicans, I say this: If you can get real assurances that the public option has to break even, and that it will get no special deals from suppliers, let the Democrats have it but ask for concessions on tort reform in return. (That could actually save some money.) The resulting public plan will be too small to notice.

To the Democrats, I say this: If you want competition in health care, you won’t get it if the public option can make deals its competitors can’t. So either give the Republicans hard assurances that the public option would have to break even and not get special treatment, or, better yet, just give it up to ensure that some useful health care reform is passed. A public option is neither necessary nor sufficient for achieving the real goals of reform, and those goals are too important to risk losing the war.
This sounds like sense to me on both sides.  I had been wondering the same thing myself.  Legislative horse-trading goes on all the time.  Why wouldn't Senate republicans say to Obama: "Fine, we'll give you a limited public plan, and in return we want real meaningful medical malpractice reform."

Maybe they did, and Dems said no (in which case they are idiots).  Or maybe the republicans aren't really interested in actually making compromises -- their path to electoral victory leads through successful opposition.  I don't know, but it's a pity.  Health insurance reform with a public option and malpractice reform would be the best of all possible outcomes. 

(Lions via WaterTiger, just 'cause they're cute)

13 August 2009

Healthcare Improvement

An Op-Ed co-published by Atul Gawande, Donald Berwick, Elliot Fisher, and Mark McClelland:

10 Steps to Better Health Care - NYTimes.com
WE have reached a sobering point in our national health-reform debate. Americans have recognized that our health system is bankrupting us and that we have dealt with this by letting the system price more and more people out of health care. So we are trying to decide if we are willing to change — willing to ensure that everyone can have coverage. That means banishing the phrase “pre-existing condition.” It also means finding ways to pay for coverage for those who can’t afford it without help.

Both of these steps stir heated argument, not to mention lobbyists’ hearts. But what creates the deepest unease is considering what we will have to do about the system’s exploding costs if pushing more people out is no longer an option. We have really discussed only two options: raising taxes or rationing care. The public is understandably alarmed.
It's a little vague, and doesn't contain a simple list of "10 steps" as the title suggests.  However, good stuff nonetheless, and a bit of home-town pride since my institution was one of those cited in the article as a leader in efficiency.

Also worth noting that our institution does not rely on salaried physicians, as do Mayo & Cleveland Clinic, since I think putting docs on salary is an oversimplified way to promote efficiency.  It's no panacea.

The lack of specifics reinforces in my mind one key point: organizational change is hard, and there will be no cookie-cutter solutions.

Know when to hold 'em

I'm a terrible poker player. There are a lot of reasons for this: I can never remember whether a full house beats a flush (it does) and I don't do the mental arithmetic to calculate whether I should draw one more and hope it completes my hand or not. So, I suck at poker for a lot of reasons. But those reasons don't really matter when I'm playing against other amateurs, but I still lose. I think it's because I'm not skilled at getting the best outcome out of a given hand. I fold early, or bet big on a weak hand, or accept a small pot on a very strong hand. I'm a guy you are happy to see at the table when you're playing for real money.

So, just to be clear, I'm not the guy Obama should be taking advice from when it comes to negotiating strategy in the health reform debate.

Like many other progressives, I've become concerned about the prospects for the health insurance reform currently before Congress. It was going to be a tall order even before the August recess, and the angry backlash and waning public sentiment may well erode the support of the centrists, who were none-too-enthusiastic to begin with. Are we going to lose this? Might it be a better strategy to "take our money and run"?

By which, I mean that, despite the hard-core conservative opposition to the reforms, there really is agreement over about 85% of the reform package. The public option is the irreducible sticking point, with some technocratic disagreements over funding mechanisms and threshold for subsidies. The take-away from interviews like this, is that if progressives dropped the public plan, or even accepted a triggered public plan (which might be the same thing as no public plan), there would be quite a few moderate republicans who would sign on and the bill could easily pass the Senate*.

There's a potentially compelling reason to cut this deal before the final cards are played: if health care reform goes down to defeat in the Senate, it's not a given that the Democrats will be able to revive it in any form, save perhaps some trivial incremental reforms. If heath reform dies, it would be catastrophic from a policy perspective, and somewhat worse from a political point of view. It would kill the hopes for meaningful reform, and possibly deal a near-lethal blow to the nascent Obama presidency. Given the downsides of a clear loss, the opportunity to cut a deal and walk away with a win, albeit more modest than we would like, seems like a preferable alternative.

Should we? What would reform look like, absent a public option?

As much as I really believe in a public option, it's important to note that the other elements of the proposed reform packages are very good indeed. If you had offered me these bills eighteen months ago, I'd have jumped at it. We have, at least in HR 3200:
  • Universal coverage (or nearly so)
  • Individual mandates
  • Employer mandates
  • Community rating
  • Guaranteed issue
  • No recissions
  • Subsidies for middle-income individuals
  • Elimination of the SGR
It's not perfect, and it's not complete. Further entrenchment of the employer-based system may not be the best policy. Expansion of Medicaid is obnoxious. There's no automatic enrollment (which would take the place of indivdual mandates). An argument could be made that Wyden-Bennett is a better bill. The biggest deficiency of the bill, absent the public option, is that it would do very little to constrain the growth in health care costs. There is the proposal to expand and strengthen IMAC and the Comparative Effectiveness Research office, each of which should have some element of cost control. I do not think that these reforms will be sufficient to "bend the curve" back to a sustainable level. The public option was intended to fulfill this function, at least on a complementary level with the other cost control mechanisms.

This is where we're at: do we accept an imperfect and incomplete health care reform bill, or do we go for broke and try for the big win? Robert Reich put it colorfully: This is it, folks. The concrete is being mixed and about to be poured. And after it's poured and hardens, universal health care will be with us for years to come in whatever form it now takes. But Paul Begala sees the cup as half-full: No self-respecting liberal today would support Franklin Roosevelt's original Social Security Act. It excluded [long list of stuff.] If that version of Social Security were introduced today, progressives like me would call it cramped, parsimonious, mean-spirited and even racist. Perhaps it was all those things. But it was also a start.

I don't know where we should go from here, but as I disclaimed earlier, I'm a terrible poker player. If we take the modest reforms we have on the table, it's a more-or-less sure win, but are we walking away from so much more? On the other hand, if we walk away with the proverbial bird in the hand, the failure to impose cost controls guarantees that we will need to revisit this issue in a few more years, and perhaps incrementalism is in order here.

We are not yet at the point that we have to show our cards. It's possible that the tides will turn and the pro-reform sentiment will be back on the rise come September. And Obama has nerves of steel, and an uncanny tendency to get exactly what he wants in the end. I'm glad he's on our side. And I'm equally glad that I don't have the responsibility for making the call on this one.

* It's possible that all the Senate GOP are working in bad faith and, as so many times before, Lucy will pull the football away from Charlie Brown once again. I don't think so in this case: I think Snowe, Collins, Graham, Voinovich and Grassley are possibly "gettable" if the right deal is offered.

12 August 2009

Town Halls

Just got back from the town hall for WA-02.  It was moved to an outdoor baseball stadium (AA Ball, but hey) due to overwhelming interest.  I'd guesstimate 2,000 people there at least.  The crowd was boisterous but generally well-behaved.  Both pro- and anti-reform groups had done their turnout well, and they were more or less evenly matched -- if you count the many single-payer types there as "pro-reform."  The anti-reform folks were definitely louder & more passionate.)  I'm willing to bet the news will highlight the polarized debate without ever mentioning the Single Payer activists.

There were a number of very angry people there who screamed in rage, but as the discussion went on everybody seemed to tone it down.  Some people brought small children, which astonished me.  I would never dream of bringing my kids to an event like this, and the consensus is that I'm a terribly irresponsible parent!

Congressman Larsen was good.  Gentle humor, frequent reminders to be polite, good flashes of personality.  He also seemed to lull the crowd into a stupor with detailed, boring responses to the questions.  He answered most of them very well, and ducked (or misunderstood) a few.  I was impressed; I know I couldn't handle a hostile crowd that well.

It really seemed to take the wind out of the sails of the protesters when he explained that, though a Democrat, he did not support Single Payer nor the Public Option as currently written.  He gave detailed and knowledgeable explanations and chuckled ruefully that he was getting "booed by my friends," as the Single Payer folks were indeed heckling him.

And it wouldn't have been a real 2009 Town Hall debate without the obligatory kooks with the Obama=Hitler placards:

But wait!  I assumed they were teabaggers; they're not!   The LaRouche brigade is back!   Oh, politics will never grow dull as long as these clowns are around.  They make the Ron Paulites look serious and in touch with reality.

I chatted with a number of folks there, and it really brought one thing home: a lot of people at political rallies are just nuts, regardless oftheir ideology.  Seriously, maybe we need to rethink this whole democracy thing.

(Note to the irony-impared: that's a joke)


I don't know if this really adds a lot to the debate, but I'm a sucker for cute artwork and stick figures.  What that may say about me I will allow you to decide:

See here for the full series, and here for the creator's blog.

11 August 2009

Heads I win, Tails you lose

TNR's Jon Cohn makes an excellent point regarding the messaging troubles that Obama and the Dems are having in selling health insurance reform:

Squeeze Play - The Treatment
[C]onservatives have been making two separate arguments--arguments that cut in completely opposite directions.

For some conservatives, the problem with health reform is that it’s too expensive. It will cost too much money up front--and cause us too spend way too much money in the future. The more earnest and reasonable version of this critique comes from the likes of David Brooks, the cruder and more dismissive version from columnists like Robert Samuelson. Common to both is the suggestion that reform, as currently envisioned, won’t do enough to change the way we get medical care and, as a result, won’t do enough to reduce the money we’re spending on it.

Still, it was fair to say that this early version of the House bill didn’t go as far as it could. So when the measure ran into trouble at a third House committee, the administration and some of its allies seized the moment to double-down on cost control. In particular, they won inclusion of a new, independent commission of physicians to guide Medicare payment policy.
Emphasis added.  And I should point out that it's not just anti-reform conservatives making this point -- KevinMD has opined that cost controls should come first and universal coverage later.  It's a good, fair point, and I share the concern that the proposed reforms won't save as much money as is needed to make American health care sustainable.

And the anti-reform crowd can't help but seize and run with the opportunistic retort:
Well, you can see where this is going. Two weeks later, the right has seized upon that very provision to make a radically different argument. Now a (mostly) different set of conservatives are arguing that health reform will put the government in charge of medical treatment and that, as a result, we’re on our way towards harsh rationing of care. The hysterical version of this argument--Sarah Palin’s delusional invocation of Nazi-like death panels--is the one making all the news now. But there is a less over-the-top version in the writings of libertarians like Megan McArdle.

There are a lot of reasons why I think this criticism, even the saner version, is wrong-headed. Among them is the fact that there's no precedent for this sort of behavior by politicians in this country--or in other countries like ours, where the public expects (and gets) a high level of health care services without rationing based on age, medical condition, and so on.
It's a classic catch-22, isn't it?  No matter what the Dems do, there are infinite ways to attack it:
  • The bill's too complex. (You want simple? Single payer.)
  • It's rushed. (Dems have been trying this every decade or so for 60 years, and there've been two years of policy groundwork going into this.)
  • Obama let congress get too into the details. (Clinton failed because he didn't engage Congress.)
On and on and on.  These attacks will need to be weathered; it's part of the process.  Hopefully, Obama and the Dems will listen somewhat to the former concerns about cost containment, while not taking too much damage in the PR arena from the latter.

Please note the difference

Nate Silver clears some things up for us:

FiveThirtyEight: Politics Done Right: Not All Socialist Countries are Alike
In Canada, the government is like the VISA card, and the health care is like the things. Kinda crazy, eh? ('Eh' is the Canadian word for 'huh'). We'd never do something like that in this country, except for old people who don't know any better.
And though Nate doesn't come right out and say it:  Neither is anywhere near what Obama and Congressional Democrats are proposing.  Not that it makes a difference, since the reactionaries are out in force as if they were seriously considering using the old and feeble as base ingredients for Soylent Green.   But it bears repeating from time to time.

Channelling Crazy Andy

You know, Andrew Sullivan has become more and more sane over the years, and I may just have to retire the "Crazy Andy" moniker.  It was bestowed during the period he was trying so frantically to reconcile his "conservative" principles with the pig's ear that Bush was making of it all.  He's over that, now, and firmly back in the reality-based world.  Anyway, he's got a great series he's been running called "The view from your sickbed."  A couple of excerpts, with emphasis added, but I don't have anything to add beyond the stories themselves:

The view from your sickbed
When I was 6 months pregnant with my first child, and on complete bedrest, I was laid off. I was unable to look for a new job, being so late into a very difficult pregnancy. My doctors that had worked with me on this high-risk pregnancy were not covered by my husband's insurance company. We decided to use COBRA for me so I could continue to see my doctors of choice. My severance ran out the day my son was born prematurely, with complications from having the umbilical cord around his neck during birth.

The first bill for his expenses came as I was leaving the hospital without my son. When a claim was denied because they said my son had a preexisting condition, that was the final straw.
The view from your sickbed
I was at risk for a kidney stone due to medication I take. I had pain like a kidney stone. I had an x-ray the revealed a kidney stone, and shortly thereafter passed a kidney stone. Still, I was given the CT scan on the slim chance that my pain was something worse and they missed it, leading to a malpractice suit. If rationing means that hospitals give the care you need and not expensive tests that only serve to cover their legal assets, I'll take it.
The view from your sickbed
I work for a national insurance company and it's my job to pay hospitals and clinics for services performed. Now when I say pay, you should think of that in air-quotes. [...] So while your readers are being charged $50 for asprin; my company employs an entire department just to shuffle bills around while they decide what they will pay the hospital for that asprin.
The view from your sickbed
Our twins are preemies - born at 34 weeks. [...] It should have been done in the NICU, but it had been missed. She scheduled us for the following week. She had to order the vax since it was quite expensive (a total of about $16K.) Two days beforehand, she notified us that our insurance company had denied the coverage as too expensive.

We then proceeded to try to get the insurance company to cover the vax. Our doctor called. The NICU doctor called. We had conference calls with them and the insurance company. We worked up the chain of command at the insurance company. We had it done and paid out of pocket. What choice did we have? Finally, we pulled in a specialist and managed to get high enough up the chain to get it approved. By this point, it had become something of a crusade for the various doctors involved. Two weeks later, my company's health insurance premiums went up 30%.

Coincidence? Who knows. But when people talk about rationing under socialized medicine, I always think, "You know, we have rationing now, it just hasn't effected you. Yet." And mine was one of those highly-vaunted "gold-plated" private health insurance policies.
The view from your sickbed
I should be one of the guys conservatives want to help. I started a small consulting business in 2008 - the third time I’ve struck out on my own. The last time I did so, in 2003, I was on COBRA from a previous employer at $365/mo. Now, I’m on COBRA from my last employer at $792/mo. [...] I’m a very healthy 45-year-old, and I’m HIV-positive. My meds work great: no viral load, healthy t-cells. Aside from this, nothing wrong. But I can’t miss even a day in coverage, because the list price for my HIV meds is $1,798/month.

So far, I can handle the $792/mo COBRA, but it certainly puts a damper on my profits. I decided to try and end-run the application game, knowing I’d be rejected. Every rep encouraged me to apply anyway, but applications can take hours to complete – who has all that time? I started telling them upfront I was HIV-positive. None had any advice, save “there might be some California state plan you can apply for…” There’s no central source of information about this, nor does any private insurer have any incentive to help me find a plan – I’m uninsurable. The hours I’ve wasted searching for an answer are turning into weeks. Even those of us that can bite the bullet and tap savings to pay for private plans simply can’t get them.

The view from your sickbed
So while Republicans are screaming about socialism, they ought to look to their attitude on liberty and see if they can’t find some good reasons to support healthcare (insurance) reform, rather than throw a collective childish tantrum. They ought to be mad at themselves for electing that dumbass W who didn’t champion this opportunity to lock in public loyalty for decades when Republicans controlled both Congress and the Presidency. What we got from them was a massive giveaway to seniors to secure the 2004 election - not real, positive long-term fixes to serious long-term problems.

There's one great point that bears repeating: we have rationing now, it just hasn't affected you. Yet.

And this is the glorious Panglossian best of all possible health care systems that the anti-reform activists want so desperately to preserve.

Another day, another falsehood

This one is pretty innovative:
The [House Reform Bill] bill will give the government direct access to Americans' bank accounts at any time, which, in some variations of the lie, will then be raided to finance the legislation.
This apparently has its origins in the thoroughly discredited chain email that WhiteCoat recently republished.  It's caught on with Limbaugh and the teabaggers at town hall meetings, though, so it's worth debunking.

Fortunately, the good folks at Talking Points Memo have done that for me, so I'll just reiterate their findings:

Your Bank Account Is Safe: Running Down The Latest Winger Health-Care Lie
The section of the legislation on which this claim is based states that the bill will "enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance advice."

As Politifact points out, the bill's legislative summary makes clear that the intent of this section is to "adopt standards for typical transactions" between insurance companies and health-care providers, and continues: "The legislation generically describes typical electronic banking transactions and does not outline any special access privileges."

Just for reference, it's a good thing, from a provider's point of view that doctors can get paid via electronic transfers.  They are faster, less likely to get "lost" or misdirected, and cheaper to process.  Electronic payments reduce the days in AR and speed payment.  I'm often amazed that we manage to get paid at all by the paper-check-insurers.  I'm forever finding checks in my mailbox that were sent to the wrong address, the wrong provider, to the patient, etc.  It seems miraculous that they find their way to me at all (even if it is ninety days after the date of service).  So, yeah, bring on electronic transfers.